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0918A 0363A 0364A
Y - PY: ( ' _ ..__ ___ __. ._ _ . ._.._... . .. _ . _ .._... _. msu�e,ot o tertiiimre of Workers'Com ensationN �� oharcelifedto'nherOeof3cA3e800,��b����'�ent1se1 �-����APPLICATION FQR�BUILDING� PERMIT ��.� �� � , Insurance f p cy,NoW�C8520419'�omPa�yAmeY."H[T1.'`AssUx'. Co. � 1 COUNTY OF LOS ANGELES BUILDING AND SAFETY �� � � � • � — _ ._ Certified copy is hereby furnished. ., '+ FOR APPLICANT TO FILL IN eu��olNG � ' nooQess 21251 Fibre Court ��Certified'copy is filed with the county bullding Inspeo- --" BUILDING 21251 Fi.bre COl]rt. ' ' 'lion deparfinent."�• � `� - �� � ADDRESS � oa�e 10-30-85 APPu�a„rWalnut Lifestyle arr nP 91789 ia„i,TY Walnut, Calif. � �'�CERiIfICATE OF EXEMPTION FROM WORKERS•'' ` ' ........ . ..'.. . . .. NO.OF BLDGS.. ...... .... .. NEAREST .... .�._.. ...._...._.._.._.. ' � ' � �•�COMPENSATION INSURANCE . . Si2E OF tOi 7964 SF NOW ON�Oi e . Oi055 SFTaSYll.11 tAR�& LlI1COlI1 � hThis seUion need not be completed if tha permif i's�for ona � - - � - �-� �� - � �� � � � � � ��' "'� �P e� �NQ ' ,�;, � pAGE� PARCEI �� undred dollars(E100)or less.) ,, . tRACT BIOCK LDT No. � ownies Walnut Lifest le No632-0134 u zoN �nP I certify that m tha perfarmance af the work for which ihis � � �� >. permil is issued,I sholl not employ any person in any manner . , SPECIAL�---� - - - � -- .- - � �- .a ,. becomesubjetf toTha Woikeri Compensmion Ldws �� � ADDRESS- � -- S Il`AV2-'"�� ��� �� '� - ' - CONOI710N5 � O so as lo . .. . . ,.� . • . . ' .. , , ,V Eiem ti ,`_ . .,9 . . UTY .. ' . .. .. .. ZIP . . _...._ _. ___. . _. . . . _ NOTIPE�TO;YP�ULICAo d ibecoma subject'to'he �.�.�.. .. . . ...^..I �� `10-30 85 PP ARCHI7EC70R ,,i EL � rfiti[ote of ENGINEER R•J• �d1�71C�C & tLSdo. 261-0383 �ISTRICT.,,,. GROUP NPE, . ;FIRE,. P SE�BY,. e�Workers - �� - CONSi� j ZONE Compensat on provisions of the Lobor Code,ryov must forlh- � 'W with comply witk soch rovisions or.this ADORE55 � I ' ' ... ._ ...._ �a. p permir shall be �.__. � deemed fevoked.�.,,, . ,,', ,; ,�,, . .,..,� CONiRACiOR Wa]nut �.i.festyle No632-0134 � STATISTIC4L CLASSIFI TION �,L' / APT. CONDO. � �� .Z IICENSED CONTRACTORS DECLARATION .. :�: -. .-.-.... .. . _-.-- --,. --. . . . � LwSS NO.�oINELL.UNITS ��/ �� � I hereby affirm that I am licensed under provisions of Chopler 9 �. ADDRESS 950 N. Tustin Av.��� No379£373 � ' (commencing with Section 7(100)of Dwision 3 of the 0usiness and . _... __.__. __ _ ,,, _ __ __..__, _ � � � . -LIC. . ... � SEWER MAP Professions Code,and my licensa is in full force and effect. . CIN i7[� CIA55 - � "" � �%, -- /� �--VAUDATION-�-�� -' ._.,r . -... , .. , . . . . . 5Q Fi. 1HOO� NO.OF .1_ .. NO.OF 1 CHECK BK.WPG.� V . � LicenseNomber 379$7j t'ie.Closs�l ' S¢e sroaies FAMIL�ES ONE , „ , , .„ .,,.. . . .�.... ,. . � VAIUATION._ : . . ._ . .. ' . . , . . - DESCRIFTION OF WORK � �����Frd� N� � . .. . ... -. . . ., '., , , .. _ . co�vd�wiaalnuf Ia.fest��P �a�e noo � s 6 3,4 5 5 , , �I am exempt under Sec. � f - �-� Al7ER � `G 9�,��� . . .. . ,.. . .... 8.8P.0 for this reason . . . . . s `�J�-f�/J.���y/ \ : � - . . REPAIR..❑ V /Y�-�..� ..... �'e..• s�.�23 .. � . . .__ ._ .. . .._ .. _... . . . : � USE OF DEMpI � i' . '. EXISTING BLDG. ❑ ._ .. -'''y.�.�,Q 3 , ..... Signaiu.e� - -� A�aliCqNT iEt. FINAL � ' . NER.BUILDER DECIARATION PRiNTI � - .DATE --- . . .-'-'- -�:'. ----...• e.j.� h�.j=..� � �I hereby affirm thot I am exempt from�ha Comr6ctor i Licenee � �� � � �� � �� �. - ADDRE55 950 N. Tustin Av. �1�1@1III � . � ��••.. �• � �• Low for Ihe following fedson(Section 7031.5 Business and Fu+a�� �� � :._I 1,2 2-8 5 ' 'Pra�e5510�5 Code): "'. .... . ..... ...._._._.. .._._.... .. ....., PRESENT _. � ._. ... .. .. _. ' ... ' aBUILDING ' . .. .. , I, 05 owner of the prope�fy, or my employees with ADDRE55 � wages as fheir sola mmpensation,will do the work and � " �- � �' . " � -- �- - , . the sfrucWre is not iMended or offered for sole(Section ����TY � ; , � ^ �� ..5��� '�'� , � -�7044,BUsiness and Professfons Coda). �- . ...-. .. -'�- MOVING... . ... .. ...- . ....TEL.. ... ...-.. ... . .(,�.-.�Y - -� .. '�3(?J,q� . CONTRACTOR NO � �I ' ' ' '� I,as owner of the property,am exclusivaly contracting p� 1 ! ❑. .with licensed contmctors fo canstruct tha proje[Y�Se[- �-- ADDRESS ......... ._.�.. .. . ... . ����-�-'_�.-....�....... . _ � . e 1\. `v�.._N-... .. , . . •j 3 . � tion 7044,Bosiness and Professians Code). �; �� ��� ., . � �� ����� �CONSTRUCTION LEN�ING AGENCY � � - � - �. REQUIRED -YARD 'HWV� � fOIAL SETBACK FROM._. %I i.� .�\jt• v f . •R � _ ' SET BACK PROP.��NE WIOTH ��i 1 hereby aifirm Ihat there is a constrodion lending ageocy for FRONT �1^ N , � • o ��..�.�, . , -ihe perlormance of the work for which this permit is issued - -- �p,�. - � � ����� - � � � .. .. . .._. . .._.._... ....... .._._..._. ._... (See.3097,Civ.C.)� SIDE _ .._ ____. . . 1 .'__. ...._��J.� 7-�lJ.. ... o .. _. _. P.L.__ __.. ._ ..._ . .. ...... .. "'-. . .. . _'.___.'__.._' . . .... ..F.G.V_� . . . _.... ._.... ._ .._.. .._.... . ..._.___ .... � �1� � ���. Lender's Name �. - a /�./ 'y IDMA Ref.N .� . . . - lendeYs Addre55 -. . . . . . �.... .- ..- P.0 Fee 5...�f�. . Permir Fee - 7 U'���.C��.. . �, �{�• •�• . � . -I tertify that I have read this app�icalion and.sfale that fhe ... ._J.._.,�U.."..��y�Issoance Fee�-��� �.<J(-J �. LDNtq P/C M ��1�L1 , _. .' � •�l 7 r1 J n � obova informotion is mrrect.1 agree ro com ith all Counry Investiga�ion Fee \ - �''' 3 ordinances and State laws relating�o ildin construction, !` ��'/� � ' � �� , . ... ...__..._ .. . ... - Toml Fee...7� e�i(..J. LDMA Perm:.N . �. _. ._ . . . _ • ..L.%:i,�.':�S .'-� i ond hereby authorize represe i of this o�nly to enter . ; opontheabov - Yoned rty(ar' ection r oses. l�r�Lj� ................ . . , ..... . _. , ... . __. . . .. _ . . .., Oa.� 7_-.i�.6 __ ' �- �--�- - -.. ._.. _ ,. . . .. ..-- - � . , ._ __... .... .. � � « -C� . �I �-'� SEE REVERSE FOR EXPLANAiORY UNGUAGE � . � ' . .. . SignaforeafApplimntorAgmt .....-.... .pore.__ ._._._-_ _. . _.. .._.. __. . _. ._ . _._._.__,_ _... ... . _ .___'.�.... _ ___ _ ..._..___--__.._ _� .. _ .. �� ........ ........ .�OO� ( - ..ir.. - _ �-n' '+.... _�.. " ' _ ' '�," " ' "�. 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