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ti T 'i - . ..,. .. � . . .___,..__"'._"'"_ '_ . ._. ..._'""""..� _ ..... ......'_". ...... ..._........ _ '"_"'_' ___ ..._'_.... ... . . ._.........�..._ ._ . . . -. '" ��' WORKERS'COMPENSATION DECLARATION . -- �'� �.'.�.,'..�`"� • � �....'..�:...' .. "' ..... , . . . . . . . . . . . ._. . .__. , . . _... ; �hereby affirm that I have a ce.+ificate of.coneenl to self APPLICATION��FOR��.BUILDING PERMIT insure,or a certifimte of Workeri Compensotion Insorance, � . � or a cerfified copy thereof(Sec:3800.'Lab.C.) .."` . _ . . . .. ..... _. ._ . . -'-. . , . , . . _ - - -__-'- - - . ' ' ��'nn' � ' ` ' 30�C COUNTY OF LOS ANGELES BUILDING AND SAFETY ... , � PolicyNo. 7��0�5��mp�uvrQ4 N$t"il1TllGii[3P � gUII�ING � � Certified copy is hereby fornished. ' - .. . ' FOR APPUCANT TO FILL IN ADDRE55 $50 N. F03�t ' �`_Cerliiied copy is filed with�h�e counly boilding inipec- ' � BUILDING , , �. ii0�depOrlment.� � � A�DRE55 D'ole�.�.�619.�.:. .... ...: ... ...�,�. . .,.. .. �---�- --- -- - �. -� . '" �D'iamor�d Baz - ----z�r .91765 . Diamorrl Bar -86�Applicenl"THE.ANDEN GROUP an - ioaum '. ' ' CERTIFICATE Of EXEMPTION FROM WORKERS' � ''- - � - --� ' "'"-�-�- NO.OF BlDGS.--�-- - � -• NEAREST � - � ��-.-�- �--����•• • , '� -�� ' � ���COMPENSATIONINSURANCE '��- '��-"�-• 9ZEOFLOT nIOwONIOT cRosssT. _ Hi�h�Krnb-�&.Golden S r S � , (This section need no�be�compleled if the permiYfs for'one � ASSESSOR. ., ----�- �- � � -- � � " � , . _. .._._ � .�. � � hundred dollan�E100)or less.�. TR/+" '357� '" BLOCK LQT; 7 � /,AqP BpOK : ::� 7AGE PARCEL . . . . '. , - owr.�eR- THE ANDIN GRUiJP No.967-9541 ! ''^"P : USE ONE � •)2�Y,! I Cerfiiy ihal in the'perfo�mance of the work for whith Ihis �„� � . _. � ✓Y' �Y permit is Issued,I shall nol employ any person in any manner p.0. BOX 3329 : � - s�eaa� �-- � � - -- ��- � � � �� � ---- ADDRE55- - - " - � --� � -� -���� -' " ' -' G'lTt� CONOITIONS so as to 6etome Subjecf fo the Workers'Compensolio���'�`'S; ENGINEER C� CONST - 'V . ,-;_ ..: . .. ..� �. � . .__ _... ..'__ - _ _ . ._ . .__ . ' , an.__.. � ziP_91722 ! � O .�e' � ��� � �Applicant ' ARCHRECT OR TEL. DISTRICT_. GROUP NPE FIRE PROCESSED BY _ .'�.. TICE TO'APPLICAM: If,'after�r�5aking ihie Cerlifitate of Dave Szan AIA r,o.445-4073 ' mption; you shouid become-�wbject to the Workers --- �7 , A' �� Z�N '/y� � •�uV+ � Compensation provisions of the Labor�Code,you musr forth- qDDRE55 �a '`�3 � -� ,"� - '� ��� � --"J ' �' � wiih�comply wi�h such pro��s�ons or �his permit shall be ..._ ... • TEL. • � STATISTICALQASSIFICATION APT. CONDp. .. Z � i hereb offirmE thatDl amrlkensed . . , CONTRAROR ���1 G�P r�o. ' -- - - . deemed revoked. ,.. RS DEQARATION,.. ,, - ��-- ---..._ --- -'__'-_� .- --. .. LiC: � - - _ . ��GLASS NO. � DWElI.UNITS �' y under provisions of Chapter 9 ADDRE55 AS 3}JOV2 NO.371.Jr8� ' . �! � (commencin with Section 7000 of Division 3 of the Businessand _._ SEVJER MAP . .� " " . , 9 � .. .. _ ..._._...._..__.._ _ _ . _.UC.. _ __..B___._' . Rofessions Code;and my license is in full force and effecf. CiT'/ � C1A55 � - �-�K - -��� � -- � '�' �--"VALIDATION--�'� j �' ���� ��� SQ.F7 NO.OF NO.OF CHECK � � � : . .. . . . . .. . . . ..� . � Licenie Number37�"SHO�' � '�Lit.Class� ' '.'. SIZE '17H6 - $TORIE5� �� � FAMILiE5--1. . . ONE- i ' ' - . ,. VALUATION ;`'�� -�� �.1.�6 9,9 A�- . ... . .. ,. _. _._.. ... .,, -- - i �- ��]]F',.�i�'� G�(]P� • � � 6�],9-HEl - -� DESCRIP710NOF WORK S� 12 fc'lIIl].I. - - N� "� co�r,d�,e� F oo�e - - Garage_445 SF' ADD � s 65,320 . ; TM. . . �2 . .. �I am exemp�under Sec. -''- � - ' - -- �- � ---�-- '... . . - ALTER - - �-- '-. . . . . . . - ❑ f , � � e26£iUJr — _ .. . ;. , B.gP.C.forihiSr¢asOn ""' REPAIR_� '. j.. . . - ' '"' - - � ".' � . . ""'--'-. ..""-. . � • om?���Jcs.o i � ..._._.__ _ .. . ..._. _. __ . USEOF • i Dale: EXISTING BLDG. DEMOL ❑ - _'_ . __ ...._ _ � �- -Signalure . .-. . ... . .... .� - " AP7LP NTT� �IN � NO. � FINAI . ' O H.2�-S b OWNER-BUILDERDECLARATION -- _- --'_ - . - - -DATE..1Z 'L2-? . ...- .-----�- - ----'---- • ' . _ . . ._-� - - � . .. I hereby affirm that 1 am exempt irom ihe Contractor's Licensa �r �}�pVe : , , , ." ,, ' ' �' w for the following reason(Section 7091.5,Business and ADDRE55 FlNAL'" : � � ; ti "'-._... ...-_-___......_._._. .... bfesstonsCode):� - � raeseNT , -BN � - � - . ��'�' � . , i _ BUIL��NG � I, as owner of the property, or my employees with ADDRESS __,__. . ..._. _.. . ' . _ . . . •-�.�-��O.O.A.':'.. � � wages o4 their sole compensation,will do the work�and �����, ,, 1 ' .-.,... -_ i r.. ' ir the srrucrure fs not tntended or offered for sole(Section � ^; ''^ �-"� ', , , ��e• e s : i --- 7044.Businessand Prafessions Code). -�. .-.... . MOVING'� � � -- ' TFL.' .. . � '-'- ... ^.-- � ' -- - j � I,as owner of the property,am exdusive�y coNracting CONTRACTOR NO. ' - ' -. . - -wi�h liansed contractors ro constroct the-p�o�ect�Seo- ---- -- - ---- �---. . . . . .... ... ..... . . _..... , �- -- . . ..._ � 3 I � 9Q00 fion 70E4,Business and Professions Code). ADDRE55 . ' • °J 9 Q���i. � � REOUIRED. -�OTAL 5Ei6ACK H � . . . .- ..'.' '- ..'_-'. � .. " " ' '- '' ' � "�- -""'�" �"CONSTRUCTION LENDING AGENCY�-""--"-�" ' -" 5ET BnCK YAR�' HWY - PROP.IINE w�orH ' �. 0£t 2 2-E b I here6y aHi�m that there is a construction lending agenty for FRONT � �'�i � � -�ihe�performanca of ihe work For which Ihis permit is issued..... .- P.L - - -�--. . . - ..-- - -. .- - - . : . . _ .._ ......--..'-_��''- ;.'.',•.•-- ---��-'- - �� (Sec.3097,Civ.C.). SIDE � �.r';..�� � . . . .._____.. __ _ CAI1t1S1E'S1{-3�. I�.�.1PY)1S � P.L . . . . _ _' .- ____...d. ._.._._. _ �_'.. ....' ' .. . . Lender's Name , `� '• � � . . � , . IDMA Ref.M ;:r .'�,s i -:I � . ------- _ . 231 S. LaSalle. Chicaqo II, - v.c.F��s 268:65 - ve�m��Fee ._._ 379.50 _ ._._. .. .. _ .. Lender's Address ' ' _ � '�' ; .I certify�hat I have read this applitation and slata that t�F)93 . _ _ _ �ssoa�ca Fea--- --ZO.SO � LDMA P/C�� -- ,-- - �------ --- _ � obova informati 's correcf.I ogree fo tomply with all County Inves��go��on Fee , � ' ordinances a S le laws relaling to building tonsltuttion, . ..--. To�al Fee -�-�- �� � LDMA Perm.#�- � � � ' _ . .. _ ._ . _. .. . . . _.... . ' ' '_ __"_ ' _'._ .._'.. .._.- _ ond hereby ut ize representa�ives of this Co�nty 10 enter ' , upon tha - ned properry for inspetlion urposes. ..-LD�-_ . , $75- ,-.-- - ' $3r> - " ,---- _'- "-. - ._-•"-'_ -'--' � SEE REVERSE FOR EXPLANATORY LANGUACE � � ' ' _ _ _ _ ___ .._'_- - � $ignalurao PPliconlorAgen�._ _'__.._..-� '. . .__ ..._.. ...._'"" "' " _' _' .. .. _._,_ .._..:_"_..._"_'__"�, " _'_ '_ _' _____" "_. .____. ._ +- I � h" 1 ,.. .. _...M._.�__ __,___...__v_ ,. �_ ..._ .a.. . . . , . . -. . _._ ._ , ...,..ry. ,...... .- - . - �'*± n 2 0 0 � '*+ v+ o v,o v p v+ :,,v �- .�. ._ s- — - - -- -�- Z ;-r ''o Q °c T s �u 3 0� ? `° $ ,°-r o m ; a o; 'o m o io u c o i � c�o I �o � � a o= � � ,•�, -^ ^� 0 4 v - !m' � . � ' 'Z x �,� ° ;� � , �° �• �--° ��` m' ,0 � S i^ . , T �� �c o"F H � wl � , , 0 3�" ii� o o � ,�u a i � � � 0 1O o `" < < o °m � � � , 3 0 '�: a - _ ai I 7 °a o j = -°o � � 3 �o o i � ��'� " ., m m o: ', o V.O. . 7 i M� � m . . � ' :7 ' __ � . 1 , N . � ( ^ � O �o ' I" . . i r i- � ,. 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