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1125A 1126A (5)
, , .. __- �--- -��- -- ....._._ . . �-�#VORKERS'COMPENSATION DECLARATION • � .� _.. ' ..'.._'.._._"-'-�""-'" �-----..-..:_�. ..._..,(_, __.._.._.._...- -'.... APPLICATION-�FOR� .BUILDING PERMIT � � ' I�Aeie�y'affiim iha�1 have�a cerrificate•of consenf fo self � �-- inaore,or a certiffcate of Workers'Compensalion Insuronce, � or a'teqified co �hereof(Sec.3800,tob.C,) "' " -� � -' � - ��- � � - � - - , �� 73WC 5-274-0004 Natlonwide• 10/A COUNTY OF tds ANGEIEs i BUILDINC AND SAFETY � �� ' - PolicyNo. � �Company _ .. - ...i �I .Certified ca a hereb furnished:.r.:: �• � y BUit��NG u"' PY' Y °' FOR APPUCANT TO FILL IN A�DRESS 844 N. FeatheswOod Dz'ive � � ��':Certified copy is filed with 1he couMy building�inspeo- ��� BUILDING g44,N. Feathel.zaCod�Drive • � �llon department.,. . . . . . AD�aess . . . n ... � I : , ! oa�e .6 19-86. q � � THE P.I�IN GI2[�lP - . Diatiiond Bar - -_zia 91765 �anun Diatrorxl Bar PPlicont CITY � -'�� , '� ����CERTIFICATE OF EXEMP710N FROM WORKERS'� -"�' � - -- -- � -�-�� � - �� NO:OF BtDGS.� � - - -----�� NFARESi . _. . �_ ..' ' '� � •-� '�� COMPENSAiION INSl1RANCE � ,�����.��,���.: S2E OF tOT NOW ON tOi cRoss sr,High.Knob�& Golden-Springs � ' (This sectian naed nol be complefed i!the�permi��s for one -- - .- -35761. . ..... .. . .. ... . $_ assessort- . �-- � . ---- ��:�.,-������ ' � hundred doliars(S��)or less.) . . .,, raner BLOCK LOT NbpP BOpK`''�' PAGE: PARCEL . � � P1�IDEN GRWP No 967-9541 ' u o� rN+P - .. ... . . .. - .. - OWNER ' _'_' ' ., I.ceAify thm in the performance ot�he work for whith�his p�p. .z �3 ' �- � !} permil Is Issued,I shall not employ any person in ony monner ADDRE55 P.Q.BOX-332g- J � SPECiAL�.-.- --.- ..-- .-- _-- . .... _.__. -d � so os to betoine subject to�he Workers'Compentotion Laws. __ . . ..'._".. .. ._ . .. ��O LONDITIONS ' . , _.. . � ,•.- `,O . . . _, . .. � � _. __ ENGM ER �R • _�Y.. ZIP NQ . _ _.' '. . . . . _ . _ _ ..."._ ' � . e . � . �APPlicant .�... _ . . . � , �O � �TICE TO�APPLICANT: If, afler�moking�his Certificole af [�Ve S j�a 1}Qrj-t}O'73 OISlRICT_. .GROUP I TYPE _ _ _ � fIRE PROCESSED BY.. _:� � (�mpfion, yov'should bemme su6jec1�lo Ihe�Workers' � J CONST.�'1 �-Z E W �ompensaiion provisions oi the Labor Code,you musl(orth- ADDRESS 314 N. F].]CSt Arcadia 91006 [d . �'�J /�/__ wnh comply wi�h such provisions ar ihis-permit sholl be � TEI. STATISTICAL C1A551FICATION . . qpT. CONDO. ,,Z deemed revoked..,.�•.,., . ,. ._.. .. . 'IHE �IDEN CiFN�LTP _/�.�,-� �� UCENSED CONTRACTORS DECLARATION� , � ��TRACTOR ��' , aq55 NO..�I�DWEII.UNITS-�r�- � �� � � ' I hereby affirm fhm 1 om litensed under prov'isions of Chopter 9 AODRE55 AS �OVB No,371580 � (commrnc��g wi�h Section 70W)of Division 3 of the Business and .. ,_ ���_ . SEWER MAP i .. . _ .. - -� - - . . . Professions Gode,and my license is in full(o ce and effed. �iTy - nqu $-- -' � .._. . _...___._ __.. . � T ._ . . .... .. � . ... �. ,-� . .... � . BK. � FG. VAL DA ION - . 5Q KT-1446 .. No.oF rao.oF ]. CHEIX f., � � ... , licenSaNVmber �715$n ' ''llc.Clois-B �� � � SRE S70RIE5 � � � FAMIUE$ � ONE - . �� -� � 2.�� ' �.:.�. .� , . � . ...,., . � S� le.famil VALUATION ' --- - ---- . , ' � ... . _ DESCRIPTIONOF WORK � Y�-�---�- NEw._.._� . . . ... -- : .� ' ir�•�• •��2 1� Controctor ��: NI�FS1 C' 7P oate 6-19-86 s 54�000 . aoo � � i , ; ❑I am exempt unde.Sec. G3Y'3 e 470 5E---......._.._ _... .a -�.e 2�}-� (� �.-' ALTER V _ . . .... , . .. . , �. B.BP.C.for this reason REPAIR. � -��s- �-----� ----'-� ' - - Z 3�,T-�J�.� .__.. -... .. o • ._._._._'_.._-._ ..._., USE OF � . ..-Dote:� --' EXISTING BLDG. DEMOI ❑ . � � . � _._. � .__ ..D�22-86. . .... SignaturB ...... . .-- '. ' ""-' ' APPIICANT TEL. �� FINAL ` OWNER•BUILDER DECIARATION f�ztNi� N�� .DATE �(,Z, � . -. .__. . ._, -�1 here6y aFtirm thm I am exempt from Ihe ContmUor's Licensa - �� ��-� � - ` �� ' --" -' ��� �, -�- � -���-`��� �'� As above '�w for ihe follawing reason(Seclion 7Q31.5,Business ond ADDaE55 � pNA����� � ,-� L -� - �� IBSSi0n5 C�de):' '_ "_' ...__._._.._._.._ ..... . _ ._- PRESENi �Y _ ..<yIM 4�� " ' -"� . . . : • . .. , ... .. . - BUILDING ' 1 1, ns owner of tha properry, or my employees with AODRE55 . I �'.�-� 2 b� _ ' � .� �-�wages aiiheir sole compensotion,will do the woik-and � - � `�`ITM ►' ' � •- � - �- �--- -�---�----S - � ' � the efructure fs nat infended or o(fered fo�sale(Section ; ��• o s • •� �• ""'- 7044,Business ond Professions Code). -' -'- - '- MOViNG - -� � - -- '-TEI.-. .... ..-.-- '--'-- - �-. ... -.. _ . ......_ . .. � � 1,at owner of�he property,am exdusively contratting CONTRnCTOR NO. ' ' � �J 3�i�Q . , with Ilcensed contraaon to tonstruct the projeu(Sec- .... _ _ .. _ .. _ ----...- - .------- . . . _ . ".- - ---. _ '_' — '. ._ . tion 7044,Business ond Protessions Code). ADDRESS � ���" � _ F_�'a J�G n(�U' , �. ---�� -""" CONSTRUC710N LENDtNG'AGENCY-�-��-�'- -- - _REOuikE�_ YARD� tiWY T��A�SETBACK _.. . Ri T.. _ � � � SET BACK pROP.IINE WiDTM �� � --. � - � - "n -'- �. � I hereby afFirm thot there is o tonztrucfion lending ogency for fRON! , ��.2 2,-8 6 • . �-the performanca o(the work(or which Ihis permil-is iswed -..-.. .P.L- - -- -�� -- ---. ..__- -.---. _ ' _. _--. . . :.... ._'-'. ..-----._ - -. - ' (Sec.�097.Civ.C.)• SiDE ' � � , • ' ' � � P.L , . .. :"''!1'i� . , -_.'_"_.. __ . . . _ __ ' . . .; . . � lender's Name-�.'OI1t1T121'1t3�. I�.�.]1'IOlS - .. . . ._ ---- - - �.�_: . _-".-- -__. � _ . ; _. ...- �.'�.�..... •. � P.C:Fee S �� •.. ' ._ Permi�Fee 325.SO.. .. IDMA Re£M ..�; )�� . � � �� � . : • lender s Address23l_ 4 TaShc l o� i g�p"=�lT, ' .16 ' ` � � = - -- - . � . t _I certify thal I hav reod ihis applimtion and sto�e�haG�.AG93 _ . . _...... __. _._._. .. _ iswen�e Fee--�10.SO--- lDM4 P/C N... . ... _ _ . .;.._ ._�_ ..`�� � " '� � _ _, _. c above informm' correct.I ogree to comply with all County . ., "- ' , Invesngo��on Fee , i 3 .ordinances 5 te lawe relaiing ta building consiruciion. .._. iaio�Fee�--��-336.00-_.._. -IDMA Pmm.M-. ..._-. .. , .. . . i and here6 au repreiemalives of this County�o entar � � �� � -' ._ . ..-_--'----'`--- __ ... _.. 5'� upon -me ned prope��y for inspection purposes. ' ' -" _. .- - -----'----.... . ._ - _ � - -� : c � _ .. . . ... _.. ....._. , . . . . �-- - � __.. .._. o � j����9a SEE REVERSE FOR El(PIANATORY LANGUAGE I _- . .' ..."_'_.__'_.. _ .'__ _ .. . _'__. . , . �'- ' Signa�ure of ppiicant or Agent �-��-.. —. �e " ' - '' ' _'_' _ ' "'_ _' �� ' � -__"'" _"' � . . 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