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1077A 1078A
�....,, ..WORKERS'�COMPENSATIONDECLARATION --'-'...- -.-' "" _- ' .". . ... ._..._"'.._..... ..._.__�. _.._.. ._""..-._'.- --_ - "'_"""""-'_-'-'-'--'•-. �.... ,. .... . ... . .�. -.. I heieby effirm that I have a certiticate'of�o�;e��,0 5e�f --- ��-�—��--��-�APP�LICATION FO�R�.BU.ILDfNG �PERMIT-- ���� ��� insvre,or a tertifico�e of Workers'Compens6lion Insurance, . , . �. ,. ..00,lab'.C.)' : ..•. � ----- - - -- -� - - � � .__.... _ . .. ... _ yr7�C005-279c0,8�y COUNTY OF LOS ANGELES BUILDING AND SAFETY �cCCertfedco'nfsherebeCfurn Nat7.0I1VT1C�{2 . - � ---- ------ `--- --.. _ ... �.-._..--------� - - - - - py y ished.• �,. • .,/ FOR APPLICANT TO FILL IN BUILDING � � ADDRESS $3$.N. Feat'�ezzeoocl Drive . �';Certified copy is(iled�with 1Fie'covnty bbiliJing�inspet• '""'" gUILDiNG ; �fiondeparlment. �� ADDRE55 838 N. Featherwooci.Drive i Daie��. F>�Z9�HF)..�,Applicam��TFIE ANDIIQ.'GE�UP CITY Dialnorld�Bar -- - �- Z1P.91765 ' �ocs.un � �'', .t CERTIFICATE OF EXEMPTION FROM WORKERS'� '� '-� "� -��- � - �- ----�-�-� -NO.OP BLDGS.-... ---. .-- NEAREST__._._... ..__ __ . ._.�_ ..__._...._ , � S�ZE OF l0T NOW ON LOT CROSS ST. _..... __ -. . � " � GOMPENSATION INSURANGE' � ' • ' (This section need not be completed I(the permi�is for one � - � �- - --- -- -- - -- ---� -�-•- -�----' �ESSOR , -- �--- � ---- .�=�-�•� � � hundred dollors($100)or less.) . . ,, . , � TRAQ .357(7]. BLOCK LOT NO. �. MA7 BOOK ����� � PAGE� PARCEL , . ... .. . . . -- . TE� GROIIP . 967-9541-: u�jzo!!!...111��� nv,P �j� �/� OWNER' - '-NO. /// 1 , ��,.;l��y� I�certify ihot in ihe performante of,the work for�which this � �� - 'Y permit is fssued,I shall not empioy any person in ony manner $PECIAL ��� -�--� -��---�-�- � ���� -��-- . . . _____ ADDRE55 P.O•BOX--33Z9___.._ ___.__-'__..—___ .. f'� ',u so as ro 6ecome su6ject Yo the Wo�ke�s'Compensotion Lows. , �•,, . . . ,,,�. . .� .a,.- ,, .. ... r 1Tld 9�. ZZ . CON01T1 NS ,. , . , . � �e ...��. -. �. .. -�APPIitaM ...� . � .. . � � �., ..__.._ CITY"_.� '_. '. ._ .._.ZIP_.. � . . , .... ..__... _ __- -_ _ _ _ : _'_'."_ .,. .' " __ ..00 V� ". ARCHITECTOR TEI. DISTRICT_ ,GROUV IYPE , FlRE_. PROCESSEDBY.. �.,� TICE'i0 APPIICANT: If,'ofler'�moking this Certifitate of Dave S 445-4073 � .. .__ .._ fNGiNFER �Y NO. CONST � �ZON (J emprion;'`you�shou�d become'subjett to the Wo�kerz' ----� � 1.rS ].a ..,.,..- �,W Compensalion provisions of the Labor Code,you musl forlh- qooeE55 � �� � -_� _ _ _�._ �a with�mmply with such.provisions or lhis permit shall be TEL. � STATISTICAL QASSiFlCATION APi. CON00: �Z � deemed revoked., � ...�;,.. �_,,.� ..., .�,,.. . CONTRACTOR nm. �' ' - � ..._.� � .. . .�r'� " . tICENSED CONTRACTORS DECLARATION�: .'� - -� _--- - � - -���- � �� - �-- �i��,- cin55 NO.� � � DWEtL UNitS� ' I hereby affirm thol I am licensed under provisions of Chapter 9 ADDaE55 � �Ve No. 37158Q�- �R�P - (mmmencing wirh Settion 7000)of Dcvcson 3 ot th'e Business and __._ _ _ __ _ ���,_.__ � ' - �' ��• � ..;. . --- ---� ------ -..._ _ . . Rofessions Code,and m license is In,full force and eHect. GITY Mss ' '-�------��'��- -';�-� �'�� ---� ' � - -VpLIDATION'�'�� - � Y :.. . . . . ... . � � . �� . . , _ 5�.FT. NO.OF NO.OP _ CHECK_ BK� �'' � � �.•� ��,� � : -.� � � � ' � � � SIZE $TORIE$ ���� fAMILIES ONE • ' ��.�' "��' �',�. ' License Number '371SHO °: ' Cic.Class $ ' � � . ....� - � .. ., •^ � VAlUAT10N_._ ' � � .. . CoMraclor �� ANDIIV GRDL�ote- 6�1�-HF) -..'- DESCRIPitONOF WORK -S1IX�le-fc�Ll-tY._ . NEW - � f 87�680 '-...... ... . .. ..._� .. .... ---� . . . .. : . .�. . ADD � � , ; � O Z�I��..,. ❑I am eaempt onder Set. - -.. ... . ..Cidrd 0 674 $F- - - --�--�------ � --.._... --- �--- , � ALTER � � #� • a •G��. : ,,., .. .: . .. ..,-, , , � B.BP.C.for this reasan .. REPAIR.❑ �-'s--'- -- '-. -..... .' � ' ' "'._...._..__...- -.: -- - - useoF •, ` ; I •�3469 -- -Dote:.... � EXISTING BLDG. �� �EMOt ❑ . ..._._. .. . .. _ .. -�--� Signature '--. . - . .- . ' "'' APPLICANT TEL FINAI ' ° •�3 4 6 4� � ._ .. . OWNER-BUIIDER DECLARATION GRwt NO. _.DATE ...' . _.:.. ..... . . .. . � � __ -I hereby offirm�hot i am exempt from the Confroclor's Licensa - - -� �7OVe - -- - - - - - ' , , , ; D Et.�C,,."8.b- � � �'�w for ihe following'reason(Section 7031.5,Business ond ADDRE55 FiNAI � ' ' � i ' bfesslonsCadeJ'.. _ .. _..__.. .._..._-- - .. �-- vae5erlt '- 6y - - . .. . . .. . .=... . , BUILDING � I, az owner of 1he properfy, or my employees wifh ADDRESS - wages as fheir sole compensation,wili do the work and � ' � '. , the struttvre ie not imended or oifered for sale(Section IOCAIitt � � -� � .. , - 704d,Business and Professions Code).- �� �-' �-- MOVING- - -- � - - �- � TEL �- � -- �- - - - ��� � - �-�- �-� ��--��-- �-���-�� � � �,OS ownEr Of tfle pfOperfy,am ezt�usively tontra[ting COMRA�TOR � NO. , , � wi�h litensed tontracton lo constroct the projett(Sec- -. . . . --- - . ..- -- �-- . -._ ' .. - - -- - -. .. '. ...- -�-- .. .. �ion 7044,Business and Professions Code). /+ooRE55 , .... .. '..CONSTRUCfION IENDING AGENCY'- -- ... . - SET BACK � YARD. HWY TOTAPROP.LINEFROM . ..WIDTM� . . . .. -. . . . . ... .-� -' - -------� . -� ,�;.• _''_ I hereby offirm thot there is a cons�roUion lending agency for fRONT . ��'• ' ._-�,.��;� � - � � �� �1 07,8A � -the perfarmance of-�he work ior which Ihis permil is issued -- � -P.L.. . -. -.. ----- ------ - ---- - - - --.... . ... .. . . . . . . . . - � '-� . (Sec 3097,Civ.C.). SiDE � ' � 'o ."'__' " '._. . . . .. ._ .... . _ ..._. P.l. . � ' "' ' _ " '_ (.{ �'1'<''C.I � �r'a • o • • �':._" . . . . '. _ _ _ .�_ . ._. � lende�'s Nome COII{:lI1L'I1t31�1111I�fJ1S .I ° r 5o r.e.F�a s 334.69 Permir fee-- - ��Ref.X �`�' ' � I �4 f:9,0 0 , _ . ___. ._. • _ Issuonce Fee L�MA P/C p-- _. ..-_.... �..�� 231 S.-LaSalle Chica IL 478.50. �����•�5;. - lender's Address 3 ' '� ° >4 r.9,G 0=�� � I certi(y that I have read this opplitetion ond stote that.the � 1�.50... . _ • Y ---- - - - � � -�- �- - - � -- , �. ' _ '_ � obova informati is covecl.I ogree to compiy with all Couny ���p���yoiion Fee I 0�.�2�8 6 '�'� '7, _o�dinances a tale laws relating to 6uilding constrvction, _... .- -. .-.-_- -__-- --.-- -. Taial Fee--�--489.00-.- IDMP.Perm.M . . .,. ! and here a orize representatives of this County to enfer -� � - � �� � � - i ' � upon th -me ' ned properry for inspection urposes. � ' . . ! , .__ . ._ .... --'-..._. ._ . - ._.. . - �--- -. . .._ �.- - - -� -- - - - .. . > -...--------' ".-"� -'-' '- ' � � � 8�j SEE REVERSE FOR EXPLANATORY UNGVAGE ` � 0 .___._SignceureofApphmn�orAgenl��--�- -- - - Doie_- _ .__ ..__._. . _ .._ .___ -______ . ..___ . _ -. . ...'.._.. .___. ' _ �__.._ __ ______'_- - . .. QQi mT n= r r m T fn T r � N T� _� .�" _T _S" C __'_ _'._ ._. Z (�1 > > O O 7 O NO O O (l� fD "<_ 1'"_" . 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