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0916A 0341A 0342A (4)
...Y WORKERS'COMPENSATIO .., ., ...�. .. .. ..._ . ..._._ . ..... .._..... , . .. . . . . . .... .._ . �. _.�- ...... msvre,or a cer�iftmre of Workers'N DECLARATION .:,, .,..,.,..... ....- ... - i_.__._. ......... . .,.1 . �J'J. Z . � � � . , _ . .,._.. - � -- � . ..... .. _ ___. __ ...----� --.. I hereb offvm�lhalJ hove a�e�,,f,�a,e of�o�,e��,o 5e�f , APPLICATION FOR BUIIDING PERMIT ���� ' � � Compensat on Insurance, . or o cer�ified cop'y thereof(Sec:3800 1a6.C.� " ' "' � �� �OUNTY OF LOS ANGELES : BUILDING AND SAFETY � yNo. W('R520dl�ampany.Tumr. Am .Accnr, �Cp .._..:._-__._. ._.- _. . ' '' . ....•.' . Palic Certified copy is hereby furn�shed FOR APPLICANT TO FILL IN Bui�o�NG 21236 Fibre Court ADDRESS �'�Certified copy is(iled.wilh Iha'count'y building�inspec- "�'� BUiLDING I ., , "tion depa�imenl.�� � ADORESS uo�a in_Z� n�r_aS �Applicam' uT�7.,.,+- r;�,;��:,i„ an Walnut zir 91789 . , iocAurv Wainut '• . '. _._ _ . . . . .. .NO.OFBLDGS. ... .. ._.._.....� NEAREST � . ......_..__............._. . CERTIFICATE OF EXEMPTION FROM WORKERS �' � ` ' .._ ... .... � � �� ��GOMPENSATION�INSURANC�'��'�������'.`��� � SIZE OF LOT 69E)O SF NOW ON LOT CROSS SL .WdSil1II Il�S� L111C0 (This�secrion need not be completed if�the permit is for one � � - �� � � � � ��-� ASSESSOR.,9zQ � � , � 1-'] �� � ' - hund�ed dollars(b100)or less) . TRA BIOCK LOT NO. µqp gppR PAGE PARCEL . � - -� � � TEL. - U5�ZON �P � - - own,eQ Walnut Lifes le- - r,o.632-0134 � P Y P P Y YP tiaich Ihis {/_�� �. � � � � ',} so s,tos6ecome Isub'elct�a he Worke seCom ensany manner . . . F' SPECIAI.. . .. ..-... .- . .- .. .O � p nLaws. � ADDRE55-9rjO�N. 5 � " �"�� �- CONDITIONS ..V .... � ��. ..., . -. �... .. .. . .. . . Dote 'r1�-30-85�qPPLcant. .., �. �..,.�. ,. . � ENGINEER • _ . . � ..___..___ . `NNST.� . . ,.. � . r�O . . CITY_. -. . . 21P _ . NOTICE'TO APPIICANT If� after�makm �this Certi(i[a1e Of ARCHITECf TE�. .,.DISTRICT_ GROUP NPE , _ . FIRE . PR ESSED BY .. ; e ' ' �. J. Marvick & As.r,o. 261-0383 zon,e v Ezemptioa,�Yoo should 6ecome+sub�ec� �o�the��Workers' �'- � �7 . / � W Compensalion provisionrof ihe Lobor Code,�you most(orfh- ADDRE55 � -� � ��" wi�h comply�wi�h such provisions or this permit sholl be . . , � ; qpf. CONDO: ,�� �2 � deemea.e�oked.,, ,,;, ,, �..,.. . Walnut iil.fes le 632-0134 .��/ ..'',' CONTRACTOR .. � .LC. , STATISTICALCLASSIF TION� . . . . .. . . ... .. ... LICENSED CONTRACTORS DECLARATION.. -� -�- CIASS NO.�- DWEtLi�UNITS�L � . . ' NO I hereby affirm fhat I am licensed under provisions of Chap�er 9 ADDRESS 9SO N. `rUSt].Tl AV. r,o379873 �R�P ., � � (commencing� dh Sec�ion 700D)of D s'on 3 of�he 8usiness and ..,. . _.__ .. _ - . LiC. - .... . r �. : Professions Code;and my license is in full force ond ei(ett. , CITY j�p�7e� CtnSS - - - "�-VALIDATION " ��-� ,., �. �. ,� ...�. . ,. .; . �VI BK . . � �V . . .. . . . . .�._.. �.�HOO� NO.OF._].. .... NO.OF."..1. .. CHECK � ' . UcenseNumLier �79R7� �iC.Cl6ss R-� SIZE � STORIES FAMILIES ONE � .. . ,. . . . � � .. . . .. ALUATION... ._ � . ._ `- � .. � . � ,C91,( A . .. .. • ...' DESCRIPTIONOFWORK-�WOOCI fTBRIe... .. ...- NEW.. . . .. COnfmCtorWd�i'17 "T.1'FPRI�V�PData '. ..�,.' .. ��r: • • • j . ' 0 s` ' i4 • 2 ❑ . . . ADD ' ,. .. .. . _ .. . ._1, I am eaempt under Sea .. '. . . ... .. - ALTER ❑ ; I •3� �1,�� � ' � - _... .. .. . . s.�.)�� � B.BP.0 for�his reason . � . QEvn�R � C( � "" '' � � � �� ` '� .—� .. USE OF U ���� � • A .� �i `�,'7 czi : . ..__.., ._ . _ .._ ._. ❑ � ' EX�ST�NG BLDG. DEMa ' -�-- "Signafur � � � APRiCAraT � TEL FINAL ' - ..� . ..�..�.l�-�Jr , ' OWNER-BUIIDER DECLARATION � PRiNi NO. - DATE-�-- �� �--�-��--- � - �-� . ___._ ._.. ... -- I hereby otfirm that I am exempt trom the Contrattor's Litense � 9SO N. Tustin Av. �11d17E1IC1 �. . . . , � •• - "� low for tha followirig reason-�Secfion 7031.5,Business and ADDRE55 qNAL- � � � - _. . .. . �. _ ,. ._ ...... ' �Professionz Code):...__ .__..., ........... ..�_- .... .... ... P ENT :,-By- . .. . � -... ❑ BUR�ING � � � � I, as owner of the properry, or my employees with ADDRES$ l�1 t v `. ,_� �j'n wages as their sole mmpensation,wiil do the work and � rL 4 . . �, the stroctore is not intended or offered for sale(Section ����rr , � � �� '�' ti . • � �i j �: ' ...._. .-7044,Bo5inessandP�ofessionsCode)..-.. .. . .. .- � MOVING'..._. . . _- _.. ..' -� TEL . ........ . . �. . '� .. ; . �. .❑ CONTRACTOR . r1�... �. � ' . ... _ ., I,as owner of the property,am exdosively conhacting �P Y '� � ° �n 3� -wnh licensed mntractors�to tonstroct the project(Sec- -� ��� -� ' ���-�- �� �-� � ----- " � ������ �� �/ � � , Iion 7044,Business ond P�ofessions Code). aooRe55 . � 3 � � ��, ��„ r r ;� _, ;; , ..RE�UIREO ...TOTALSEiBACK . � � - � � � � C O N S T R U C T I O N I E N D I N G A G E N C Y�� -' "�- � Ser eneK Y A t t D H w v PROP.LINE wiotti� , � .; O l� /_�b I hereby aifirm that there is a constructlon lending agency for FRONT N � � Ihe performonce of Ihe work for which this permif is iewed ..- .. ..P.l.. . - --. ... . ... _..... �... ..... . -... .. . .._. . .. .� . .- - -�` .. .. -- �n . � (Sec.3097,Civ.C.). . SIDE � .S�1��n�?r� � 'u . . . . . . _ _ .. .. . . P.l. . ... ._. . ... . . _...__ ..__._._. . .. ._ . % Lender's Name . .._ _ ..._.. .. .. .. . � . ' ' ' � � . ^ ^".� LDMA Ref.M � � • , � � .. _._ ._ . ."'". .._ .__. .. _ ... .... _ ._.. - - P.C.Fee E- / .� Permil Fee� � .I�LV ' •�I / `��. - Lender's Address t � � �.y7 i ' �' Q � @ .I.cerlify thaf I.have read this application.and stale Ihat the .�___. ..._._. .7.���.���IsswnceFee"'.....I��.���� �IDMA P/Ck��✓� ,- --i.....� a ),.�.'::7,. . y abova information is correcf.I agrea fo ly wi�h all Covnry Investiga�ion Fee • � � 'J�'� - g _„ordinances_and Stole.lows relati o bu'ding,tonzlrutlion, __..,_ ._.._____ ._.. . �.-. Tolal Fee �Sl� �LOMA Perm:N[,�C..�7 � ' �'� !=��(`- �� ; i and hereby rize rep otives o is County to enter � ' � Upon fha o e-mOMi pfOpef f inspe[li pur OSeS. - SEE REVERSE FOR EXPIANATORY LANGUA� ' � ,y u _ _ _ _ �_,. c , _ . _ _ _.. _ _ /I.� �,�' E , . , , ' . ._Signatura of Appliconl or A ... . .. . Date .. _. ......... _.._. _ ,. - - _. ...__... .. . . ... _. .. . ...... . ._. .. _ _.._. ..... ._.... 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