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0915A 0369A 0370A (4)
. . ., : _ _ _... .. . _ _ ___ ._. VJORKER$'COMPENSA710NDECLARATION • �b�D���CATION 'FQR',_BUILDIN� � � _ �, :�... .. I hereby af6rm thm.l have vi certificote of consent�to,self PERMIT �� insure,or a certificate of Workeri Compensatian Insurance, r r , ....-"_. ., . __ , .. or o cerfi fe copy t ereo((Sec.9800,lab.C.) � ' '�' ' - . ._ .. _..._. . ' �� COUNTY OF LOS ANGELES � BUILDING AND SAFETY ••,.- ;' . WC8520419 .: „" P,trier. f-Im. As'sur._Co. . _ _ -- _ . . ; PolityNo. Company - -- - � - - - Certified eopy is hereby furnished. •' "., + FOR APPUCANT TO FILL IN BUILDING i ADORESS 21253 Fi.bre Court � Certified�copy is�filed�wi'th�he�county building�ins'peo- -"-�� BULLoiNG � 'fion deparlmenL �. � �. .. ' ADORESS . , . i oora...10-30-85 �n i��amti'1a .:. . - ..___ � PP 1nut�.LifestYle �,Tv Walnut Z,P 91789 �a„�,TY Walnut ` CERTIFICATEOFEXEMPTIONFROM'WORKERS' � -`-- -.-..'-�-"� --�-�-�--�--`---.'..NO.OFBtoGS—.-. -. .. . . .p Ne.aae5i � . ... ....._.. . .. ' . ... "'"��`'� � COMPENSATION INSURANCE �"�•'"'•� SiZE OF LOT]_3 [} 6 SF NOw ON LOT O � CROSS ST.WdSI'L117 ri.&.L1riCO1T1 (Thls seclton�need nol ba tompleted if Ihe permit is for ane --.-.... .._ .. .- ...._..-'—�--�—"- -----.... -..� ASSESSOR..r .. �'.- '.�. - .. .- .•.. ' .hundred dollars(§100)or less.) .. , . TRAQ 4�'�3 BIOCK LOT NO. 1MP BOOK � PAGE' PARGEL ., . . �. . .,.. TEL � U5py ONE MAF , � Ptertif fh6t in,fhe erformanPce�f t�PwOrk for�hich,lhi4 � OWNER'-W81Tlllt�LTP2St 10 '�--�"NC�3Z-OI:34--� v�� N� i � �.,,,-�.. � �} Y, . , P . .. � . , v ermit is issued,I shall nof em lo an erson in an manner . ' SaECial�. -- --�--- -�-- -- �-- ' I � so os l0 6ecome subject'to the Workeri Compensalion Laws. - ADDRESS-' � -- � ���'--�-� -�---������� i CONDITIONS � � �0 . �� "__ ENGMEERT� . - __._._._._�'ASSONOZF)1-O3H3 ... ... . , .... , .,. ,,., .. �. � i DISTRICT... GROUP� _'... ... _ � ..-_. . V -- Dare10 '30 85 APPIfcaM . `� NOTICE TO APPLICANT: If aNer'making��thrs'Cerfificola of � J ��i� TYPE_ . _ FlRE . 55 D BY_.. i� I Exemphon; you shou�d become sub�ed�to•the'Workers' CONST � ZONF Compansotion prowsions of the Labor Code you mus�forth- • • j � �. � �_ � ,a . wiih comply.with'mth provuions or thie-permil shall be'--- /+ooRESS .- .. .. •� cor,rRncroRWalnut Lifestyle No632-0134 � srnnsTica�cv+s Fi noN arr. mwoo. Z deemed revaked..�� ..�. 15�� ,� o:.� ..�. � ', �.. ,,,j.. LICENSEDCONTRACTORSDECL4RATION i ���. . ..-. .-- �-�...... .. . .... .. .. . .. . .LIC.- -- -�-- : CIASSNO. � DWELC.UNiT9l� . ..... .. . . .� � I hereby aifirm that 1 am licensed under provisions of Chapter 9 ADDRE55 950 N. `I'USt1I1 AV. n,o379873 (tommencing wilh$ection 7000)of Division 3 of the Busiriess and __,., -- -- _- IC. - .--- ��R-��7+P /✓� ' � Pro(essions Code,and m I cense is in full forte and�etfed. _ SQYfT • NO.OF _ _ __ NO.OF _`..__.. .CHEIX ' `�`� � �-VAUDATION � ,�� . . .. ... . . _ . ,..9K pG " ' ; . License Number'379873�` lic.CloisB_�� SIZE �-90D�-� STORiES 1 FAMiUES 1 ONE Y . .. '_' ' C1P.55 � . , .. , . ,.. I ... ... _ .� . . , . � VAIUATION .. ' , . ,. .,..� . . , Walnut Lifestyleb 10-30-85_—_ oesca�arioHOFwoRK LGood frame. ._ - Ne,v ._.; _ _;_-.------ �G�1 �A-:-, are ❑ = 1 ' , . , . . .. .. ADD ' '� • • c'): � B.BP.CxamptunderSec: ..._..- -'... . ....._.. _.... -�G• •_J ❑ on rac or,... . , ,1 ," ALTER � , � : � �� .forfhisreoson -_ - .__. . _;_. ._. l.o. �i �� 7 . "" REPAIR-❑ �Q g//OQ . ..; _. ' _ _ .__.._. __. .._ -� �•'�" USEDF � � .... . e' EXISTING BLDG. �Ma � - . (.�__..1+C� � _.. c : .,,. _-'_ I � , �$ignaiul � -�y APPIICANT TEL. � FINAL � ,. .. ,� OWNER•BUILDER DECLARATION -'-'--- PRiNT NO - ._. _�� .-DATE. _ . ..,. ... __1 ._ ..'_._....., ._� ���G-.�::�.... � ��1 hereby affirm that I am eKempt from the Co roctor's litense 95o rt. Tustin Av. Al'13t101IC1 • � low for ihe following reoson(Sedion 7031.5, Business and ADoaE55 FINAI'�`� ' � ' " ' �� � ' ' '� 'Professions'Coda)i .... .. . .... . ........ .. -- "- PeE eNT . ...BY,. __ . _ _ ... .. ._._ ..' . , .... BUILDING � � � � I, as owner of rhe property, or my employees with aDORE55 � � � ' woges os their sole compensafion,will do the work and ---�� --�'- �-��- '` � � - / ' - "' ihe structure is not in�ended or offered ior sole(Seaion ��`��TY � �f� �Z.�� - � � __.. , � � . _7044:8uslness ond Professions Code). --- �- -� -----� MOVING- ��------... � ___.... . ._......iEt.-. . --.-.__..... , ._.._� .. ... �f . ... . ... • • CONTRACTOR NO. � n ` Y , �u-• �?3 1,aa owner oF tha property,am exclusively tontrocting {, G i _.O.- with Ileensed contractors to-construtt the projecf�(Seo---..- - . - --_. ..... __. __.._._. . .. ,.. .. . _ . . _... . .53�--'�- - ..... �.. � a. F3�7�9 a. .: r tion 7044,Business and Pra(essions Code). ADDRE55 . � � � � � ._ _ . _. . .. . REOUIRED IOIALSEiBACKFR M.. X � ._�..._ �'.... _..'_'..... .• •.;_7..`�.Lu_� �CONSTRUQION IENDWG AGENCY- '� �- �- - �SET BACK YARD' HWY- PROP.LINE WiDTH N I here6y affirm that there is a mnsfruction lending ogency for FRONi � � J � � ''=��?'�- ..fhe performance�of rhe-work for whitb this pmmit is issoed ---.--- �-P.L----- ---.._.. .__, . ...__.. .... ..... .. .. .. . .' ---_. _-..n,-_��__ ._ :_ _._._ ;.._. . - - -. 03,1 : �Sec.3097,C�v.C.). sioe �z G 3 1.�0 R �� _...___... _._ _.. _. . . _ . . . .'_ ._'. .P.L.. _ ._ . _._ _ __. _._'_ __.. ._.. _ _ _ .... .__. .. . . . _ . _... lender's Name (� /, '7 c-"�' �. LDMA Ref.p � � � � '__'.... .. . . _ _ .__. . ... _ .. . .... '._. . P.CFeeS' � . ...7v �. PermilFee 7��/.""��"i. - - ! _ . . . lender's Address �/ } R --1 cerfify ihot I hove reod this opplicafion and stale.thot tha . . _. ._.. __.�g --%�-- Isswnce Fee--�G�.`�V � ' LDMA P/C M �„�� ',- I e l�9 ��O , � obove information Is cortecl.I ogree to com ly with oll County investi arion Fee_____.'_..._Totol Fee--- . �..L�"'�, -IDMA verm:M - c�� - -.- . .-.i ° °r �n�C'�C' "ordinances and Slate.laws.relating u' ing construction. '_" _'___'9'__ 11 � �:M1 �.�� , ond hereby authorize represent es o his Caunty lo eMer p�� /-�(� _upon ihe o � enNo per r inspection purposes. � � � � i _ _ - ' 7C��f:dZ1.. . - ---5 C)t� _ _. . ..-'-- . -- ---- --,_. _. _.._.... i , --- _. , _._ _., ,��.z � SEE REVERSE FOR EXPLANATORY IANGUAGE � "SlgnoNraofApplimntorAg r ...,..'_...___.-Dote' ..._.' '._..___..'__._. _.._._._.._...._"'.' '. _.. . ......_. i..._.,... 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