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1093A 1094A
„. . , .., . . , ..-----.... --- ... ___._....__�-----� --...---� --. . . _.... ___.. WORKERS'COMPENSATION�ECLARATION ....__ 7;:..: -�-;i” �,,'.: :. .. ... "^^`_ _:;_-_ -."-.:...- ' --..--'-_.. ._.__, I�ereby affirm that,l have�a ceriifim�e of tonsent�o self . � � � � in5ure,orotertifim�eofWorkeriCompensation��5��o��e, -- -� ��-��� �-APPLICATI�ON��FOR� BUILDING--PERMIT�� ����1 � oracerttfiedco y�her �i Sea38v�,�La6.C,) . .'�; . ._ ....--- . . .. . . . . . ._ _. . . , . 73W��05-��/�-0004 Nationwide� 30/B COUNTY OF LOS ANGELES BUILDING AND SAFETY ' � PolicyNo. Compony_ -� -. - �� � �- � Cer�ified copy is hereby(ornished.- . FOR APPLICANT TO FILL IN eui�o�NG ADDRE55 820 N. Featherc�od Drive � '.Cerii{ied copy is filed with tha counfy building inspec- ' " BUILDiNG 8z0,[1. Feath�xv�uod Drive . , '"tion deparfinent. . � ADDRE55 . . � .. _' _ _ ._ . ._.. . .: Date�..6-�'9-H6.. ApPlicoM �� ��IN � -. . Cltt Di�� �' z�r 91765 � �a,,�,TM Diamorrl Bar � � '. �� �CERTIFICATE OF EXEMPTION FROM WORKERS' - �-- - -- -� �-� -- ----NO.OF B�DGS. - -----� �- NEAREST__ _ _. ... . - . . '�.1 COMPENSATION INSl1RANCE . SRE OF LOT NOW ON l0T cRoss sr. Hi ti.�Kiiob�&C�Tden S T1 S This section need nof be com leled if the e�mit is fo ,. • 35761-- - . .._. _. ... ]4 assessoR. . . handred dollars(EI00)or lesa.) . P r one -- TRAQ BIOCK LOT µqp gOOK'� "' �� PAGE� PAR�L� ' �� � owNea- T� APIDFN GItOUP-- -No:967-9541._. u ONE �P C Y P . .... ---�-- I terti �that in Ihe I eriormance of the work for which this �r NO. � ��.3�f �.�. '�. pe�mil is issved,I sholl not employ any person in dny monner � -- SPECIAL - -� � -�� � ���� -� �.-� ��. ADDRE55-P•d.BOX3329-�� so az ia become sub'ect lo Iha Wa�kers'Compensation Laws. � � - -- "" - "-- " OJ'V CONDITIONS � O � . ,,u-.- ..,,� . � . . ,�. � COV1Ild 722 ...'- • � . ---- ciTv.. _ ... - -- - - nP. 91 - - - - ---, ..._... _. _... ..._ _ 'm e �'�� : •�:. APPlicanf: . .� .. ARCHITECi6Ft TEL. .. . . ' ..G TICE'TO APPLICANT: If, after making thiz Cerfi(icofe of UaVe SZy AT� L]!}�j-!}Q'73 _DISTRICT,_ GROUP,C PE ; .,.._ �RE. PROCESSED BY__ ENGINEER nY NO. " � mption, yoo'should become subject•to ihe Workeri � /� I Compensalion provisions of the lobor Code,you mus�forth• ADDRESS 314 N. F].rSt Arcadia 91006 -..- a /`3 � W Y LICENSED CONTRACTORS DECIARATION. � II be - . -� - - � ' -'�- ""� -` �-- '�- - � I hereb affirm Iha11 am licensed under ' � �� ��IN G�P �` �. STATISTIGAL LIASSIF CATION ' , APT. GONDO.� 'Z deemed revoked. .. CONTRACfOR NO. � wil com wit ,SV[ � rovisions of rovis�onsolf�Cha �-QASSNO. �� �DWELL.UNITS-�/ -- . . .. . ... _ PY P P . p pler 9 � ADDRESS � �Ve NO.37158� (commencing with Section 7000)of Division 3 of the Business and ��� _ ��R�P ', '. � . �",'' P�oiessions Code,and my license is in full force'and eHect CRY ' . ....-- -�-- C1A55.$ .. ...- -- - - - - - '---- - -� . --- ---. ._ , � ...., . . .. . , � . � . . ,. , BK. FG. VALIDATION LicenseNumber '��71550� �Lic:Clads R � -. S°EFT.1786 � sToa�s. .----- F MIOlIES-".1�"' -'CONE-- , ' . . �...... 9 3 A, . �10 . .,. , . .- ' � � . __.__ OESCRIPTIONOFWORK-S1IK�10-PaIR1�.I7__' ' NEW....� T -__ .__ ._ ..._.._ ... _ � _ VAIUA ION � � � Controcto'r"'iT1F.'AN�IFN C.FY�T1PDa�e �-19=86 ❑ S 65�320 �I • • •21. ' _'_..._"'_ ADOR � _. ...._. _ . ._.'.. '2�b E.`6 rJ .-�1 �I am exempt under Sea � - - -- Cic'ird 0�-44rJ-$�'----- � ,-'"-�-� _ _' � B.BP.C.for this reo5on REPAIR_❑ s-. . .. � . .-_._..I �`6 g.0 5 T I .. ...._.. . ". . a�i i _ . . .__ .... ...- Date: - . . USE OF DEMOL ' • U . EXISTING BLDG. ❑ _ ..: _.-._ . ' - APPlIG4NT TEL � � Z Z-F i b ._. -" -Siqnatore " - � - ----- -- - FINAL ' � OWNER-BUIL�ERDECLARATION PRINT �� . DATE- �Z Z p ' ' ...._.._ __ ......_.__. . . . _ ... ...- -.. "' - '-'- '. ... ---•--�-- . -I here6y affirm thaf I am exempt from the Contractor's License '�w for the(ollowing reason(Section 7031.5,Business ond ADDRE55 � �Ve FINAL � '� ' � �' "'' .._._ TBSSiOnSCOdBJ:." ,- . .. ..." '.. . ...'. . . . . PRE ENT 6y - - - . - . . . _ � BUILDING � � , I, as owner of the properry, or my employees wiih ADDRE55 � . �':� O Q�:A - �wagee as iheir sofe compensarion,will do�ne wo�k and � � � � � �"'-� " � �� - - � � ��" - �-" - -� � the s�ruUure is nof intended or of(e�ed for sale[Section ��+��N " �'� ^ � � ' {�• • • e��.-�• , • ---�' 7044.Business and Professions Code). -- - ----- MOVING -... , - �- - ��' --� �--'�TEI. - ' i '�'- --� - � -�'- .. . .. - ,--. . . . .- _..--- OCONTRACTOR NO. , . I,as owner of Iha property,am exclusively tonfracting � •J 9 Q��' with licensed conrrocrors to consfrua the project(Seo- ---- - - . . . . ---- �---- - - - -... -- -._. . ___.. -_. . -i._----__. . . .,_... .. __ . _.. AD�RE55 tion 7044,Business ond Professions Code). � ° "J n�,��� �i '_ _. " .REOUIRED.. .._IOiAL SEIBACK FROM_ . XI . _..... __ . ._ . . � .._._'. � . , .. ...__ .__� � CONSTRUCTION LENDING-AGENCY�--�� �SET BACK YARD" HWY PROP.IINE WIDTH r Q n 2 h�.S 6���'' I hereby affirm�hm there Is a constructfon lending agency for FRONI � u e ..the peffarmonte of ihe wo�k far which Ihis pe�mil is issued - �--- � P.L:-.-. . - . .- — - � --�- �--'---- -�� -' -' '--"---- . .. ._._. . ._.' ......... i .. .... .. . ($ec.3�97�Civ.C.�. SIDE ' ' ' ' � , • � _ . % lender's NameCAllt'1T1eI1��. I�.T12'1015.._. V.L - ---. ...._ .. _...__ �.,; .:� '�..� ' _._._._.. ..__ .__ � �,. ,., ;; ' ; ; ................._231.S..LaSalle Chica IL ._ 268.65 wn�n R�r.n ,.:� '" _ . / � P.C.iroS-'- Permitfee 379.50--..- �.�� '- --- - lender's Address 693 . . . '. : , , , � I certify thet L hova reod this oppllmtion and s�ate thar� e .- - --- --._.--- _.-. -_ . i„ue�ca Pee- -10.50 -IDMA v/C x---.._.. .- ... . -_ - .. - .-. � above information's correcl.I agree to comply with all Counry invesr�gaiion Fee ; ordinances an I e lows relating to building mnsiructivn, Tofol Fea� -�390.00 ��--- LDMA Perm.M ---�' � � " � '� � _ . _ . .___. ._ . _. . . '__ ' _ . S and here6y ut ize representatives af this Co�nty to enler ""� � � [ opon tha o -m 'oned property for inspecli n rposes. L�A . _ • � ; ...___.. _ . .. _ __._'._. _ � .... . .. __ . _ ._ . _. . _ . .. . . .. _ _. ..___ _.. ..._._ -, � SEE REVERSE FOR E�PLANIITORY UNGIIAGE" $3S , . .-. Signm�reo ApplimnrorAgen . - - _ �e - _.-- '._._.. . ... . . .. .. ..... .. 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