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1095A 1096A (5)
„ ,. . .... ::,,.,, _ - _. _..---_.... .- -..._._.�._.... _ _-�---�-- � • '•.WORKERS'COMPENSATIONDECLARATION . '...... .-. ..-_--..-.__. . - . - -'-.--.----._.' - _--.. � , . . . .. .. . . � ._. . _.__.._...._. . . .. �, ,., . .:, , . ,. .. _ . . . . . .. ... . . _ ' _ I hereby oI(irm.fhot I have a ceriifico�e,of mnsent�fo,e�f . APPLICATION��FOR�-BUILDING�PERMIT� -� ��� ins�ie,or o cerlificote of Worke�i Compensotion Insurance, or'o certified cbpy'thereof(SEC.3800,Lab.C.)`, '�� '�' - ” �� -- � " - -------'- �-� � � 7�005-279-0004�� Nationsaide�•� 30/C COUNTY OF LOS ANGELES BUIIDING AND SAFETY � � ' �' Policy o. . ,Company- . . . . - -. .-_- - . . .':` � Cerrified copy is hereby fumtshed:.�,�. .; FOR APPLICANT TO FILL IN BUIIDING + � ADDRESS 830 N. Feathei.v,nod Drive � Cenified copy is(iled�with iha touniy building inspeo �-� - BUILDING J �tion�deparlment.��`�.� ' . � .. . . ADDRESS 83 N. D ' ' .. � . . . � ' ; , oore 6-19=86':naai��a�r TF.E.,ARIDIN GROUP aTr Dial:loTid B3r� Z1P 91765-- �oca.im Diamolxl Bar : � '�'� CERTIFICATE OF EXEMPTION FROM WORKERS' � �NO.OF BLDGS.�� ----�-�- �� NEAaEST._ ., � �� .. . .. . _... .__. .. : •, � .,.,... size oF ioT Now oru ior ceoss sr. xigh-Knob & Golderi"Spr111gs"-""" " . � -35761 -- - 12 - nssessort _, _ _ . . . ' �� 'IN URANCE'� � (This section need nol 6e'completed if 1he permil�ii�for one � ' 7RACT BIOCK � - � � LOT � hundred dollors(SI00)or less.). ' MAP 600K'� � ' PAGE PARCEL so aslto be�comersub'tlf to ha WorkerseComkens�� TE` U ZOyE MnP , /����,[ � . � ,. . , . . - owraea -'!i� ADIDEN GId7UP-- - -No.967-9541 Y P � � � which this � NO ' 7 ,�. permit Is issued,I sholl nol employ any person in any manner '- -�� SVEC�at ----� � � ��-��������---�- � � � - . . 6 . . I p afiori laws. ADDRESS P.O.�OX 3329 - - --.._.__._____ _..._._. �'yy CONDiTIONS ' � . , . .. 'O . . . . . ..... .. . . . .:.. ... .. ,.,. L.'OVll'13 �.722 V e ��' :.�. ..., Applimnt.�:�.��....•. ,.- ..., . _.._.. cI7Y. ... .. . . ...........ZIP.__9 ARCHITECT TEL. ��� ' �Q . �TICE'TO APPIICANT: If, after moking this Cerlificofe oi _ �V� .52311 ATA 445-4073 _o�srR�a GROUP•iYPE� � �FIRE PROGESSED BY ENGMEER Y NO. �mption; yo��•shoold betome�subject to the�Workers' - / CON j�J1 Z�O � '� �ompensotion p�bvisions of the La6ar Code;.you must fonh- ADDRE55 314 N. 1'']SSt Areadia_91006 r� �.3 �.�" � 1 y . � d with tomply witH,suth provisions o/ this�permil.shail be .- . �� ��� G�� "- ' -"" - "' � - - y � deemed revoked., . �,,.,.�.� .�.. . � .� TE�� STATISTIUL C1A551FICATION APT. CONDO: �'2 .. . . , . ',.. , CONTRAROR , '�` _ LICENSEDCONTRACTORSDECIARATION�,.�'•.� '.' - �-� . ----- --. - -- .- � .... �-(tq$$NO. vu � DWELL.�UNITS �/ 1 hereby offirm that I am licensed onder provisions o{Chapter 9 ADDRESS As. above - � �`,',o;371580 � � (commenting wilh Sedion 7000)oF Diviiion 3 of the Business and ._LIC. ��R�P �� � ' �� . .. . __ .__ ._ __._ Professlons Code,ond my license is�in fuil foice'and eifect. Citt CLHSS $ �BK.- � -- -- -- � - '-VAIIDATION '""' 371rJ8Q, . .'�. .•..�'B�. � so.FT1786 _- r,o.oF NO.OF 1_ CHECK � :: I U Y,.7 a .. License Number v��iC.Class'' ' ' SRE S70RIE5� � FAMILIES � � ONE � � . . . ,,, .' .'.' . ..� . � . . � VAWATION , . . . , comrac�o: 'fT7F:`A1�mFTT'I:SXxiP ' _ oescRiarioNOFwoaK S' le-f�[ni.].y. . New. � -- -- -' $;• • • •21- ' uare ' f� 19-86 s 65�320 , , .,..; ' . ADD ❑I am exempt onder Sec. - -- G3i'3 A 445 SF ---- ---... _. � -- 1 �2 6 S.6 5� i • �-: '. ,...;•.. . AITFR � , ! �- , � B.BP.C.for ihts reoson � � REPAIR- � . s ...'-..'___ :._._"� _ __.__'__e..c�..(1t��7J�-. '�" USE OF ' ` � . _ _... .. .... ....- -----�--Date:-- --- ' „ E%ISTING BLDG. DEMOL ❑ ' � . . _,Q.Q.G L�S�.__� ,•.,... :.. , .�..._. APPLICANT TEL. _ . ' _. ..Signafure ------ ---'__. .... _... . fl ` , . PRINT NO. NA OWNER-9UILDEROECLARATION __ _ _ .-DATE��-..�Z�LLS�J�.....! .___,�� � . . . - ---- .._ . . ..�--_-'__.._. ._�.: -1 hereby affirm Ihat I am eaempt from Ihe Contmctor's License " ""�"� � �� � � ' w fo.fhe following'reason(Section 7031.5,Bosiness and nooaFss � `��Ve � FlNAL ' '�� '�� � - • ' � fE551on5COdeJ: --.. -.._. ._.,__""""'""""' "" _ PRESENI 'B '�.. .. ,. _ . Y '.. . . .'_.. . - BUIL�ING :-� �C,�j A" '� \ I, as owner of Ihe property, or my employees wifh aDDRESS ' ' - "..weges ai t6eir sola compensalion,will do fhe wor4 ond �-� ' - - --. . . _ . . . . ._r.--e '- ' - tha structme is nol iMended or offered for sale(Section ����TY �-� '�' •�• � • • �-�•� 1� t �� ' � t: ' • � ��� .-- � 70<4,BusinessandProfessionzCode). -....'- . ..-- MOViNG�'��� � '-- . 'TEL. .- ; .- ,--- - -....-- -�--- - - ��- �J�� ❑ CONTRACfOR NO. � ' ' � - Q.G O . I,as owner of the property,am exdusively tomrocting -- '-wi�h licensed cantracrors to constrvtl tha projett(Seo- ----- --.. .-... ..__.._-' - - _.. ..._ . . -- - . ---'- �.- -m�n-' ADDRE55 -_..-��.- -'_ ; _ -__-__i J��'!O�G O u . lion 7044,B�sinesz and Professions Coda)., . _ . REQUIRED.._ .TOTAL SEiBACK FROM XI . n ""--"-'�-"-CONSTRUCTION LENDING-AGENCY�'- '""' "-- � "�i BnCK YARD- HWY-- PROP.UNE WIDTH � �-� ��- �� �- - . � -- :�e�2-C-Pi G"- I hereby aFfirm that thera is a constroction lending ogency for FRONT ' •� ' �� • -rha performance o1 the wo�k for which this permit is issued - - -�v.l:----- --� - _--- ..__ .. . . ._ � .. . -_ _ _ . __._. _ . . ',._ ._. _ , (Sec.3097,Civ.C.). SIDE - . , . . -.'_ . -- ' � . lender's Name�A17�'1Tlelltd.�. II.I.1T101S P� ' - . .. ._.379.SO� . LDMARef.M ,��,. �. � � .�..� " '--' . . . ..-- •�- - P.CrFeeS�"'..-..� PermitFee .. . ' � Lender'sAddress 231 R_ T.aSallP, _ i d�0 n. � ' - I certify that i h read Ihis opplkation ond sfote tha��93 - --_ .--__-.•6. ._._ Issuance Fee----lO.SO .. LDMA�P/C k- - _. .._ ' , ' � ' obove informa�' n s correct.I agree to comply with all CouMy Inves�igation Fee � � . ' _ordinon[e5 d ofe lows relating lo building construction, Total Fae�-� ---390.00�- ��-� ���DMA Perm.M � ' � - -.-_ __ ._'.__ .__.._.._. _ and hereb av i¢e represenratives of this County to enrer --�-" - -- � -- �� � .upo the - ' ned properfy for inspection purpases. �� _ , ' _. . _.__. LDMA - $75 _ -: ..$35.......---. ._ - - _ . ��,J . . SEE REVERSE FOR EX►UNATORY LANGUAGE I � -- --SignoNreo Appli<ontorAgenl. _.. ...-_�7��_"„ '._'_'... ' . .. . (�I � �! (1 S Q O J T N O (n O .O O (1� T N _ G1 _Gl' �! _S. _- _ .._ __ Z -1.. � O O � O O � W n O f9 j 0- O� O (D O �Q. .j_' ' p �p _ . c�o c s \ 3 a� � v°_ "- o � ^ n:N a o �� i ; � ^-�o � �o '�°� a o o� v '° ;• ;-'� �".Q `�� � v o :n ' x �+ °°c m o f ' ° w I � c �� n� o ° � �° D � o v3 � o c � 'o _ � ov' �'v - 3 0 = 9'. i � ° � ° - o o `o o � , o.o _ m � ;o o' � � , �i � o a '" 2 0' � .�, � m :co c � c � '" �� - o �° I - o • a '' v1' --•, � 1 � �:' � — i , , '� x � r- � ^ � � i � � � , • -. 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