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1159A 1160A (5)
Y WORKERS'COMPENSATIONDECLARATION '-'.--. .-_.._._�._._._.._...._._._.....y...___.,__-""-"'-'...__..__._._.. ___..._....--.- '..__... -.------...__.... _.r.`.��.---_ �.� �. , �... . .._, -'--•-�-'....- .,_,,.�;:'�.tV : .-. �:...... :i ',�.�i' ' � �?I:'.r:; ,insurebor�a{ceti(corieofWorkers'rCompensa�o�s��,��a��e' ���i4PP�LICATI�ON���FORuB.UILDING� PERMIT-� � ���; �orote'rlifiedcopyth �{( � 00,Lab.C.)�. �. . --'-.-_•_... . __ _ . . ._- '- ' . -. ' "-.-. ' , - _ . . _ --. . . - ' 2�7J-��D� COUNTY OF LOS ANGELES BUILDING.AND SAFETY� � �; rou�YN'd3Wc005- com�„Y Nationwi.de � __ 60 C (2 Car) __...... " _ _ BUILDING a� CerfiGed copy is hereby(urnished. � , .���a FOR APPUCANT TO FILL IN ADDRE$$ 49 P7. FeatheYwood Drive � � Certiiied copy is filed wirh t6e county boilding'inspeo- "�'- euRDING � lion deportmenl:.�. ,,,. ���. . . :.'. • ..,' A�DRE55 749 N. �eathex4.nod DI'ive ' . � , ; ,. .�.:,,. _ . . �.,. � t. . . . . . . ._..._ __.. _.__''' ""''___ _ ... ..� dare'�SS� F-1 9-8�pplicanr���`I4iF. AT7f1EN C.1_YN_iP aTr D1aTpOi'Y�{ B3ti' nP .41765 ; iocaurr D1lItUSYi BdY' ' ' ' � � � ' CERTIFICATE OF EXEMPTION FROM WORKERS'-��•" �' �"' ""'" "--'�-- ""- "- �� NO:OF BtDGS. - -�---�- -; NFARESi -�j1CJY1-Kl'Y)b-& GOI_C�eIl Spr1SY3S•- --� � � � -' �� � COMPENSATION INSURANCE" � �� � 92E OF iOT NOw ON LOT CRO55 ST.. _ : .. . , . _�. . , " � ASSESSOR_ ,:. ...---.-•.. i (This seclion oeed not be complefed�lf Ihe permit is for'one -���- - -- ----- --�-�-- --- �•- -�-- �-70- -� �; r . � - � � ' i hondred dollars�E100)or less.) � , . iRnCT 1 � gIOCK L T /,�qP gppK i � PAGE PARCEI ,r, ... ..... �_AI EN GROUP.._,.. T - ONE �P EL , '_ _ ZZZ I certify,thaf in the performance af.the wark.for whic��this DWNER-" NO:��" • �r r �. � �1.�,7j'',,,� .�} . 1 permil is issoed,�sholl nal employ any peison in ony manner _ _ p O.SOX_3329____. - --- sPean�� �� � �•--� � .-����- - ---� ��� ��- -�O. � so�a3 10 become sub'ect fo Ihe Workers'Com ensation laws. ADDRESS- •V�� ------- �� ��- �-- -�'" V�� .CONDITIONS � � �v I P .,� � . � . • ,- �� �. .. . . . ,. .. . .,., -. - an. ___ --- - ----�---ziP..._ . .91722_.` --- - - - -- --- _ .. - . � �te � ��� ''� Applicanl� ARCHITECT OR� TEL. �0 I TICE TO APPLICANT If, aher making this Certificota of DiSTRiCT._ GROUP�oae_.� _ FlRE .. _.PROCESSEDBY. .�F mpfion,�yoo shauld�become subjed-to�1ha Workers' -- -�- ENGiNEER No. 44 -4 7 � �v Compensation provisions of�he lobor'Coda;}�OU mUS�fOfiFl- ADDRESS 3T4�N. �']Y'St� p,TCdC�73 91006 ; .�__ _ _ �_3 ._. �___ n, v � �_ � _. �W with.comply wiih's�th provisions or.�his permit shall 6e ....__... �n d00Ted revoked.,,: •�-' + �• . .. , � TE�� STATIS7ICAL C�.45SIFI ATION / APT. CONDO.' � Z � � • �•� ' "'�����'� GONTRACTOR �� �IN (�� r,o. 967-9541; . � :- _ -- - --- LICENSED CONTRACTORS DECLP.RATION���, �• �--- --�-- ��p�---- �--- - C1A55 NO. �' DWELL UNITS� I here6y aflirm Ihat I am Iicensed under provisions of Chapter9 ADDRE55 P'�:�x 3329 � No. commerici with Section 7000 of Division 3 of the Business and ____.. �� �R�`'�'P ' � � ��� � � I ^9 ) --- '-�- � ---....' --.. "-'.LIC.----$ . . . .._.._., , Professions Code,and my license is in(ull forte'ond effecL Cltt C�l� Ctn55 ' -- '- ' -� '-� ' - '� " � VpLIDATION'" � � �� ' - , , $Q.Fi, NO.OF NO.OF � CHEIX � ' ' ' , BK PG. ' .�... litense N�mber�71-SHO'� ��� Lic.Class B SIZE-2375 STORIES� - FAMILIE$ 1 ONE : �' '� , . vatuanoN ' � �1 1 &9 A i oescuivTioNGatage_51Q SF'--�----- --�--- ��R -O S - _ --- � co�i�aao:'IF� ANDIN'G%XJP ba�a 6-14-86 p 86,080 ' tt• • • •2 1 �� ❑I am ezempt under Sec. - ,., I •3 3 1,t 2 + ,... . .... - _ f , 8.8P.C.(or fhis feason _. .__ REPAIR..O �� -�--- --� - �-� � -�' -- • J�I � 2� . _.._. . ._.. ..._... . - � -Da1e: ._ - -- ..• USEOF DEMOI Q . ..�.,�; .. —._.. E%ISTING BLDG. ���� � � ---- h . .. SignoFura �-� '-�"� �-- - --'- � �-� � � APPLICANT TEL f FINAL ! : . O�.L C���J � OWNER-BUIIDER�ECLARATION PRIM `IHE FNDIN GF�SXIP No. _ DATE•�-��-� ' ' ----- ---�--�- �.I herebyaffirm that I am exempilrom fhe Contracror'sticensa � � � � ��� � � ���� � - _ ' � , A�DRESS AS al�Ve Law for fhe fallowing'reoson.(Settion 7031.5, Business and ' F�NAL' . ..,_ ._.._.. - � - . ... . _. '- .'-,_ ' . �ress�o�seoda�: _._. . _ .. _ _... -- PRESENr gr � . ___.. . _ BUILDING ' : I,as owner of 1he property, or my employees with ADDRESS ' � ` �n'�',._. we,es es Iheir solt ceairer.saticn,will do the wcrk and-` - ---. ...-�--'---- -- . -- - ' the structure fs no1 inlended or offered(or sale(Section ����TM � , � ' '��v' � ._�. . 7044,�Business ond Professions Code�. - --� ... . .---" MOVING' -'--"—"`�"'"---"'-"7E1:'-..—.... .- -�---- -..... . : .. � �:• s.e •.A..�.; _. I,as Owner of ihe propeny,om exclusively wmraCfing CONTRACiOR NO. � i t ���� ' ❑ _, ..'.'_._._.'."""-_____'_ ' _....._...___'- q__ ____ ._.. ...____. .� °.�s�.JO . - with licensed cvniractarz to construct the pro�ett�(Seo--�� � "'-�"��� - � �-'-�-" � �- , ADDRESS � �'��: f: � tion 7044,8usiness und Professions Code. '�� ' � ) • .�1�';•...-..7!� ,��-•tit -� '-- - -... ---CONSTRUCTION LENDING�AGENCY- - -_ . . ._- "-sE�BtiCK-. .YaRO- Hwv_...tUinPeOTP uNE ROM._ .wI�TH --..'---�--! ...�'--"I,.�--�.... M,-Sj . ._..'. f5�..�U.V_.1 . I Fiereb affirm thol there is a constr�c�ion lendin o ent (or '-,--�^ � Y 9 9 Y fROM � . a ,'. ` ; t���,,_1� f,� .� � Ihe erformanca of the work for which this ermil is�iswed -�P.L--�--�- - '��'��'� �� ^-��+ y , ` - �8 6 �� ' P P N� `� , t„ ._ O 3 G 2 -- � - ....__ '..' _ .'_ _ _ __ __ __ __' __.____.. __ (Se[.3097,Civ.C.). SIDE . . ' ' ', t' �� ..., � C011tLl121ltdl. ILZlIY�1S ..."'_ ..- . P.L ___ _ ' _ ._ __ '_ _ . �.\_ '_ . .___. . . __.___ _ _ IY . . .. __ � ` � �,�� ...e,_ � . Lender s Nama �' , . 231 S. LaSalle,.Chica o II� _ - - - 474.00 -.--- , LOMARef.if"�i�_. - - - L ti� - -- ' . ,.. - - � - . g P.C:Fee; Permir Fee -' �, ` �. f'--��� .. tenderi.4ddress 693 ` � ._I cerlify thot I have read this application and stata.that.the _. ._ ..--.- - .. -.-_------.--ysua�ee Fee 1�.5Q--�-----� �oenn a�c x--._. _ . ... ' . .�_�_� `�=���--���_�--'--�. obove Informalio cor�ect.I agree ro mmply with oll County Investiga�ion Fea � - mdinances an ta laws reloting to building constrvctton, . , ._ ,__ _ __,.._______..____ -_484.50_------� "`�"'�''-- - -. ToMI Fee -LDMA Perm:-N. __ _ ' .__ _ _ _ .._..._'__. . .�:,'. and hereby t r e r presentotives of this County to eNer ! , �pon ha e d properfy for inspectio p r o es. . _ _ . .. . . ._ ... �.�� . ._". ._. . .__�. ' _ _. _ ._. ..�__ _.___ _ _ _._.'.. ._.._ .. . -LLY�'1�1• : $75 •• $35-- : �� SEE REVERSE FOR EXPUNATORV LANGWGE � , _"'.. Siqnmvreo} pplicvnrorAgmt .... ._ _ Ie-_ __ _.._ . . ..._.._ ___ . ._�_.__�._. _��. . ._. `. � .- . O _' " ' -' _--._ ._.. _. __._ ____ �'r� : .. ' . ' _. ..._- -- _' .. z -+ . _T --s -�' --•-`. _ o o .. � r t/� -T A� _l�9• -�_ Ep p II O � � o nv m Q o• Q �� � ,.. a om a � o T I .n v+ p v+o F v �^ y^ �, � �� �'n � >> o 0 3 S �0 3 � a. o�' D' �O � o ° � � � � �: 9 I' v ^ N �. �o co a � � v c 3H~ o:' � 3 ° � + ,.. 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