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1103A 1104A
WORKERS'GOMPENSATION DECLARA '- -'`-`- .-`__._...._....._.__....._.....,r_._---�......-_--------..,�__._ . --•'-.--•"._...._.. .. insu�e,or a cerlificate of Wo�keri CompensatT�ON . ,;.;;-,. ...,- , . ..., : ;....�.:.�„ • •_�.. --•. ._ ...----�.___. Y , � .. . _ � . . .. . �.., " ,.. , Y '.' 73WC005-27 ( 0 4 � Nat,�.onwa. 4 µ y COUNTY OF LOS ANGELES ; BUILDING AND 3AFETY f hereb a(firr+�ihat 1 have a cerfificole of-conslns � - ro�self qpp��CATION- FO_R.�BUILDING�--PER_ MIT�������� urance, or a terfified m thereof Set.3800,tab:'C.) '� -� �-"" "-� �-�" " " "- - � � �� _._-_ ..__.. ___ �- gQ ' 'de 10/B -- _.. _ . _. .._ .... .. _ -_'-' _., � ColityNo, � omp y- - • --. - Ce�tified m is hereh furnlshed.�• ADDRESS 825 N. Feathexti,�od Drive O PY Y " � • FOR APPLICANT TO FILL IN , . . ❑ Cerlilied'copy is fi�ed w�rh�he�counly bui�ding inspec '-� BUiIDiNG ��lion deparfineM: '... ...� :.. �` ', . . ADDRESS 825 N. Feathenaood Drive ; � : ; j , :., •..,.,, --.... - - - - - - : oa�a• 6-19^HG 'APPlicanl THE ANCII� GF�UP an Diamorrl BaiC zir91765 i ioc,auTy Diatroirl Bar � �CERTIFICATE OF EXEMPTION FROM WORKERS' ' -- -� � -'---�-�-- �-��`- -�--�- NO.�OF BtOGS. - � --�-- , NEAZEST._... � .,... _' � � � � ' COMPENSATION INSURANCE����•'�' � �� StZE OF LOT Now oN ior � cRoss sr. Hi�ki�Ki�ob�.&�GoTden S�T'lI][f5 � .. . .: ASSESSOR � '_____.... _.- : ::.,�,-:�� ! (This sec�ion need not ba compleied tf rhe permir is for'one --�-- � - - -�- - ----��- � ---�']]-� , ; , hundred dollars(SI00)or less.) .. ., . TRAET BLOCK LOT NO µqp BOOK'"''� � PAGE' PARCEL �' TEL. . , ' � ,.. . '. - OWNER�' U ZONE MAP � 11 ,er�mit is issued,i�i,an�o�em �"�IN�GI�UP -•�-No.967-9541-� . ,4�- '� y p � �nca of the work for whicli this �! NO. � � �y p' ploy any person in any monner . .. qoDae55 p•�•�X 3329 ---- ----------- ---, �Q�-�J CONOITIONS . . . _.. ,O I so as fo 6ecome s�bject to the Workers'Compensation Laws. �.:.:. .� �. . � .: Y I ' .,. ,.. � - - - EnRicweeetoR Dave.S-- - -AiAP.No.445-4073 . - ----- - -- - - -�----.. _._..._ ... _.......... . _. ... � �e ,. �,. , . nPa��cor,i urv. ��._ 91722 i. , . .- TICE TO APPLICANT: If;affer making this�Cerfificafe of _�iSTRICT_ GROUP�TyPE__+_._____. � FIRE ._ .PROCESSEDBV_ . �Q I mption, �ou should 6ecome sub'etH fo the�Workers' CONST: Z �rj Compensation provisions af the lobor Code,you mvsl forth- ADDRESS 314 N. F]L'Sti �la 91��6 `J__ �3 '��__ _�_ ,__ '� '___,_ _ _;a wilh mmply wilh'suth provisions or.this permit sholl be � TEI. �y CONTRACTOR ��.. ��IDEN GI�UP STATISTI�AL ClP.SSIFIC TION . APT. CONDD. ' deemed�evoked.:., .- .. . �, .. . . .. , No ; .Z � ----�'f" �--.. . .___. _ : LICENSED CONTRACTORS DECL4RATION � �� --- - �---� - �-�Ve -----�-_.....i��,_ ._ .__..__. . � aqu NO.�� �� ov,�lL uNiiS� . ,. t hereby affirm thrn I om licensed under provisions of Choprer 9 ADDRE55 No.371580 (commencing with$ection 7000)of Division 3 of 7he Business and _ _. .���r _B SFWFR MAP � � � ��� ��� � .�•�� ; . . _ _ .,. _._ ... -.-_' --'.-- _._-... . Professions Code,and my license is in full force and effect. Ciiv ��� � � BK. PG. � :. . . . .. . __ _ ____ _ , " _ _V _ . , . , , .. „ - , ALIDATION- 3�JI.�JHO �•� ' ' B ...,.'..{ "' _' SQ.FT. NO.OF .._' '" NO.OF 1 CHECK ' ; �I litense Number � �Lic Class SIZE 1446 � sroR�es FAMILIE$ ONE . ,,.i , , ,, � ' Comrocio� `�� �IN �oa�e ''6 19-86 -- - otscaivnoNOFwoeK Si 10 fdm'Ll � - sA�54,'000--'T---� ._ _` _ -' � . - .. , _..____ ,. r.e_e�• , ,'- �I am exempf under Sec. . . . �'i3Y'3C�e Q7� SF '-'---. .�-' - ADE.R..Q .�_-'-�_� {` . -'I.� � New.._ ' ' 'O. B.�P.G.fOfihlSfeasOn � ' •""_,•_.. _,.. "". USEOF REPAIR-� _.s _""._.- ....I •L�J.��.��.� '.I _ _ - �--- � - -: __.._ b._., ._.. .__.. oo,a. o�,ua � � , + _.�.+.2 3 1.1.6� ,; E%ISTING BtDG. _.. ._-. __' -i t • "' _ ---'Signarore --- -- -...... --- -- ---- -DATE- ��.30=�7 r. i OWNER-BUIIDER OECLARATION qDDRE55TT T� � -'-:"--__---O E.L�!_^H b ' Tf� Atv'DIN GId�iJP FINAL �-1 hereby affirm thot I am exempt from the Confractor's License �- �1S-� V0 -� " " " " -� • - _Law for the following reason(Section 7031.5, 8usiness and FINAL��� � ���(!J� � ' � • W�'"__ __"' _ ..- _ . 1e55ions Code): ' '- "�--- �- " -�� ' �' � DRESENT -By ' " �- ' - � -.� � � I, es owner of the property, ot my employees wifh ADDR 55 � ' ' , f� wages as their sole compensation,will do the work and- -�� ..�, ,, - -" -'" --� -- - � .4 n� ' the slructure is nof intended or offe�ed for sale�Sedion ��LiTY _.� �.\•_1�.� . . ���: j'� ,,��i _ ' � � � . � ; ..,:. ' .., - � 7044,Business and Pro�essions Code). ---- ---- �- - MOviNG - - - - � � tEt.-.... . ..- ' �- ------. -----l- - - �- � i.=• e .-°-r �--: F_..' ' �.i.�. ' °JJGOO.sz�, I,as owner of Ihe p�operty,am eKclusively coniracting CONTRALTOR NO.� '• � I J .�. wuh I�censed coniracrors to consrruct rhe project(Sec- --�- - -- - - - -- .. .. - _. _. .__.... . . --.--.--. �. ---- - ----..__.-- ---.--... _ .. � --. -i fion 7044,Business ond Professions Coda). ADDRE55 ,�� I �J CONSTRUCTIONIENDINGAGFNCY-- � ����- �SET�BACK� -YARD HWY �-�UtApROP.INEF WIDTH� / ��--�—� ' - ','' ^~i�'__• � � I hereby affirm that the�e is a construc�ion lending agency(or fRONT `~-��_�'"���� �•' rS � '-ihe pe�formonce oi�lhe�work for which Ihis permil is iesued �--.-_. ..P.L.� ' .. .... . ......'--'- �--' - --' """ ,'- ' '�"�t -. �" --�-� (Sec.3097,Civ.C.). SIDE . . .. - -, • •1 .. . . ^ '. �:.:,. ,. .:�'•-� o «"86., _-Lender'sNama �IIt7312II� IZ'ZliY�1S. ..� --- P.t. - - - - --�•..---_;;;' \,-'�.`�`, ����`:,11.1: .__ ..__I...'__..__! _. _ .. 231.S. LaS e� C cago_ � 325.50 - S ' ,� , �. ;: ; �. .. .. LDMP.ReC X' .. ` • � ...,. - ...,�� . _. .- P.QFeeE'-�23Z•�.6 -._ PermHFea__ _ ..-_ it' `...�_.__... ______. lender's Address en693 , 1 . � ',.,�� ..I tenify.thot.l have read ihis applicafion and sfota lhat ihe ___- -.-____.._.__. __.__ -. I�euonce Fee-- ! ; , .,, . .:;,�,i ZO.SO"-'_. LDMA P/C 8__"'_.._ . .. ' '____ _.__ ' above information is corroct I aqree to comply with ail CouMY inves��atian Fee � ' � ,,.ordinances and e laws relo�in to bulldin conslruction, 9 ' � � �� � 9 9 -- -- ----—.,.. __.._ __ roro�F�e --336.0�.__ '_ ' .LDMA Perm..k_ _ _ and hereby h ixe representatives of this Counry to enter ����� � � ��� �� � i � �pon the a v e ' ned property for inspection urposes. . ... _. . - - ----. .. Q � '._--_ ._. � . .------- -'�- -�--_"-'-_._..._.. -' ". . . .'- --- - �. ... . ._._ _.. --�=— -: � '-' --._.. . d `SC�dEVERSF�OR E%PtANATORY LAT�IGUAGE � __ . SignatureofApplimmorAgenr -- ta ..._- _,—__ ' .' .______.". _..__-" .-._'_'_._'_i_.___.. '__._.... ..... .... .' ___ ' �.; _..._. ._. �_...J�i� , � : - __ __ p tp- .G1- _�''_ 'o ,a �- .o- 'G� � o �—N 'T�j eL� O �fC • v ; (�v ��a o� a o T ��' fl O fD ��O O� j cD C1 � .1 -n U+O � F C7 n 0 .�i'N-J• iD, �O � � i� � � �... r. m �' p � � p � o ... p �' 'O j;�, ._y p � . . TT o o Q S � 3 � 0. a o D �p O �U: p� �; � p 'O �, ` . m � 7 .. � 7 � �O N O �� q � �n N O+O - - � N 'W d+. i : � A?.^� T ^p '� Q �� o � 7n • ✓.� j ,� - F K '� � N ..(, � O: �= - M� . � r TI �Z � � 4 � � � y, �7 - I�,V ?�•• Z. 7 O�t�7 O i O. 0. N � � '• . � �. ',: � . .�1 � i � O. 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