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1141A 1142A (5)
. . . . .. _ _..__ . .. _._ _ ,.._... .._..__... .. . . .__.... . . ..... ..�.. _ . ...... _._.. .. .---. .... ,.N/ORKERS'COMPENSATION�DECLARATION .'" �':.. � �^ . � �: "��!y''�": -: '' :" -'"' ,. J � �� 4 ......._.__..._.. �-� I hereby affirm thal I have a certifim�e oE�o�,a��-,o Se�F -�-APPLICATION FOR .BUILDING� PER�MIT-�� ���� �insure,or a cerliiicate of Worke�s'Compensalion Insurance, , _ _ ' _ ... .. . . .... ._ . _ _ . .. � oracerdfiedto Ihereof1Sec.3B00 Lab.C.��' �-��'�-� - � ���---�- ��� ` '��� • 73W�005=274-0004 Nationwule 60/B (2 Car) COUNTY OF LOS ANGELES BUILDING AND SAFETY �.� PolityNo. •� .. . � Compony ... . . . . ...-'-' . . . � - O•.- CerNRed copy Is hereby furnfshed: �FOR APPLICANT TO FILL IN BUIIDING , nooRess 766 N. Featheiw�aod Drive � Certified copy�7s tiled'with the�Eounty building inspec- -�-��� gUIL�ING � �. ��ti0�department."' � • � � � ' �-' ADDRESS 766 F ' � .� ', . . :, . . . , _ . . . Date� E-�.9-HF7. .Applicaro THE ADIDIN•..GRULTP ---- an Di�nd BdT - -._ziv 91765 ._. ..-� �ocaun Diatrord Bar � � . � ��CERTIFICATE OF EXE/v1PT10N FROM WORKERS' � ` �- � � �- -- - � � NO.OF BlDGS. � � NEAREST ._ . �.. ..._.. .. . �• �- '�'COMPENSATION INSURANCE"-�� . SIZE OF lOT NOW ON LOT cRoss sr. Hi�Yi�'Kmb���&�'�Golden-5pri S ' (This seUion need no�ba'compleled if the permit fs for one �---- �� ---- 3�J�IE)�.-- �- �-- - -- � �.9 �SSOR . • ... --- -"-� - ' '"`� �', TRACT OLOCK LOT Mqp 0pp( � ' � PAGE PARGEL hundred dollo�s(E100)or less.�, .. , i _ . . , .. TEL. ry MAP , ' ' owNea ZI-IE ADIDFI�I GRWP- r,o.�967-9541 ��� I Eertify thot in Ihe performance of lhe work for which�his �� a permit is issued,1 shall nof employ any person in any manner qDDRE55 P.�.Box 3329- -�- -�- ��� -�- � �ItYz��� con�ioinoNs - � � te',.':., ' A litant mpensation�aws. .... .. : . .. ... ',V so as lo berome sub'ed�o the Workers'Co . .•., PP 9,, . . , CAV1Tld . _.. ZiP 91722 �-- -- -. _..._ .{.-- � - ---- - - - - - -� - -' � ....... ... . . ., ";�,.;'., �..,•..,.,. .. Cltt.---- .. . _ .. .. .._ . .. . _ . ARCHt7ECT Oq� TEi• 445-4073 � o�sTa�cr GROUP. NPE_.���. flRE 7ROCESSED BY TICE'TO APP�ICANT. If;-ofrer makin "this Certifimfe of ENGwEER udV� $�� � NO. - �' - -- ,�j �mption;'you�should become��subject`to the Workers' ��-' �N q� E W Compensatiomprovisions of the labor Code,yoo must forfh• qDDeE55 314 N. First I�rcadia 91006 ��- �3 -� -�/`�---- -- --- �- - -',ydj with comply with such.provisions or Ihis•permit.shall ba -����-- deemed revoked:�,.�.,,,, � y_,,• �t �,� -. .. CONTen[TOR �'�'�'� G�P NO. STATIST�CAL C1A551 I[ATION , �� / APT. CON00. Z UCENSED CONTRACTORS DECLARATION-•�, .., � --�-- ��-� -� � �� - --� � �� � - -- -- ��CLA55 NO. � �� DWELL.UNITS_c— � ���. I hereby ofiirm that I am licensed under provisions of Chap�er 9 ADDRESS �S c'�}70V2 r�o.371580- , (commendng wirh Section 7000)of Division 3 of the Business ond __._, __ _��� B . SEWER hV'P . . � - ---'---- - - - -- -- - � Professions Code,and my litense is in foll force ond effeU. Citt M55 � -- - � - . - , VALIDATION"�" . ,� .. . . .. �. , ,. � �.� . • SQ.FiZ37S._ NO.OF NO.OF 1 _ CHECK BK. FG. LicenseNomber�� �7l 5R0�� "'�Lic.ClasiA' " --� SiZE STORIES - FAMILiES . ONE � .� [>� �.�� � ' . � ..�. .. _ ..., . . . . ... . . ... .. VALUATION . Contrdttor�lF:'�AT�IF.N �.R(�T1P Dole ��19-��i'. OESGRIPfIONOFWORK S1I1C�le fc�Ll�-y-- ---� NEW � � . .... � --� � - - }�•• • w ADD � S S6sOHO rJ 21- ❑I om exempt under Sec. .. . _ . - -� �' , ' _ �3 3 1 1 ?. __ ..__._ _.� i .... ,. , . . - AUER � - , B.SP.C.�or ihi5 reason __ REPAIR ❑ s ' • n Z��.� 2 U ' _ _. _ _____'._- -____. ._ - '� USEOF � � I ...DOte: � ' _ E%ISTING BLDG. DEMOI � . . .. _.' .. .. ' APPLICANT TEL. - ---s�9�ai�,� _..... ........_ . ... _.._ - FiNn� 0 8.2 2._a 6_. OWNER-BUIIDER DECLARATION PRiNT) NO. .._.DATE� � .. . .'." � .'--.-.-.-_".--_-..__'- ..--_.. -.I hereby affirm thm I am ezempt from the Controctor's license ����j��a]X7Ve� �� -' w for�he following�reason-(Settion 70�I.5,Business and A�DRESS FINAL � � - � '� �� ' .._—'-..'.-_. ��essions Code):'..... ...... . . ... ' '-' PRESENi - i.., ' DY . . . ... .- ' , `-1_ ,� . . BUILDING '�,-'��. '- �.�."; 1, as owner of fhe ro erf or m em lo ees wilh ADDRESS " � .. -- ' --- • 1 4.2 A': �� wages as their sola compensotion,will do ihe wark ond � , ; � �he slructure is naf intended or offered for sale(Section ��`��TM , '. �� _ ' �.. ��: :�� ; -�---�7044,Business and Professions Coda). MOviNG -iEL.- - � -- �- , -� -- � �-- - � � P P Y, Y P Y r � � I,as owner of Iha ro ert am exclusivel conlrattin CONTRACTOR NO. ' . � P P Y. Y 9 _, . � •48450 - with liten:ed toniroUors-to con:iruct the pro�ect(Seo- � - -- . .- _.....-- -... .. ..... .... .� - -- --._ .. _..._._ ... . _ . .. _ . A�DRESS ' ' �ion 7044,B�sfnes:and Professions CodeJ. 'e e[J�,I; r��•� . REQUIRED YARD HWY � �O�ALSEiBACK _ --. -. . - --- . - �-��-�`� - �- � -"'" - � -" CONSTRUCTION LENDING AGENCY� " ""'- - " `SEi BnCK PROP.LINE wiDTH � - � I hereby affirm�hat there is a conslruUion lending ogency for FkoNi � 1 �C�2 2``�C 6 ' ' . -the per(a�mance�of ihe wark far which ihis permit-is issued � ---- --P.4.---. - . . -..- �-- - - � -- . . .. ...-.._.. . .. ..t. .. ...__ . _ . .. _.. (Set.3097,Civ.C.). SIDE ; " " , 3 .... .. ..... . .. -- � - - .,.. .- - - - '- ' - -- - .._ .____ - -� - �-- - � -- �-- -- - �- � -�- - '-' P.L � Lende�'s Name C�nl7t1ri271�'3�- Illl.i101S � � . ' � LDMA Ref.M � . ,. .. _ ; . .... .. ... . .. _ _ . . __.. _ v.aF�es--- 33T-�'2 PermitFee ..G7�1.�� _ _'_ � lender'sAddress231 $ raGallP�('hieaqn TT� - � � � � � - •�� ! ..I certify thal.l.hove reod this applicotlon ond staie th�O�3- �� --- --- �-�-- -� ����� � ise�a�ce Fee 1�. �- �- ' -tDMA P/C#- '- � � -- -- I _ -- _. ..._ ... -- � above informatio orrect.I agree ro comply with all Couroy inves+�qotion Fee ' ' � E _ordinontes a 1 lows relating fo building cons}rudion. _ ____'.__ ._. . _�. To�ol Fee. ..4H�F.SO .... �pMq perm:H-- � - ., ... i and here ut i represenlatives of ihis County to enter � � upon t -me d properly for inspeclion purposes. LD� _ . . $'�cJ � $3S ' � - _ - �8 ll6 _ . . _ _. ._..-._ ; - -.__ . . �' SEE REVERSE FOR EXPLANATORY IANGVAGE ! '_-'_ SignaluraofApplicantorAgenl.._...._._..__. . ..Date -. _. .."'. ' -.. .. .. - .- ._..__ _ _._..._..'... . _..�..'.__-... ____''...'_._ '... .. . .. -_ ._" .O __. _. .� m T (�= r r m T (p �n ^r �p r r.N .-•� � .�. 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