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0892A 0893A
� .. _.._ _.._._,__ ---- __ _ _..._. ..._ __ _. ..__. _.... .__.. _. __ __.-_._ ', WORKERS'COMPENSAiION DECLARATION � �J i,,_• -� �� - � , . . � ��� �. .,,:.. . .. . .._.'-..' -.... _ . . . . . .. ,- . I hereby affirm thot I have a certifimle of consent to self APPLICATI�ON� FOR:BUIL'DING -PERMIT�--- - �: _ insure or a cer�ificate of Workers'Compensabon Insurance, - or-a certiiied copy fhereof(Sec.3800.Lob.C.�..• � ,. ' '.. . . - ' . �'--.-. .. -. —..-__ ._ .... ,. .. ---_...-----._..._. - Poi;�yNo.61WETX799�m�;;Y `HdY'tfOT'd GY'DUp COUNTY OF LOS ANGELES : BUILDING.AND SAF.ETY , __ , . � Certi(ied co is hereb furn'shed. � � BUiLDiNG � O , PY Y ' � FOR APPLICANT TO FILL IN ' AWRESS `�V� r• yyR,,,v.� � ,.Ceriified copy is hled wdh.the couNy building inspeo- � ��'' BUIIDING -" -- - �' �iondepartment '-'�" ��- � • ��� ADDRE55 1001 South Lon �IIeW ..�.. �1 � < ,; ,.. . ___.. _ _.... ... ._-._ � I � 1 ._'._ _._'.__.. . ...._..... ._.._ - ___ -__ _.__ _ "_ . � ._ . . .. ' Da�e��Applicont CiTv Ol m d B Zi7 tOG4uiv � �. � � . :.{ �: '�CERTIFICATEOFEXEMPTIONFROMWORKERS'.". '-.'--.-. . - .' -_ --. _..-./. -..... -�NO.OPBiDGS.'-----.-...-r. NeakEST_'.--`-------.....�.._.._'_.--"...-"'.-'--'--'-- ��� �-' �'COMPENSATION INSURANCE•-��� � ��- SIZE OP LOT r NOw ON LOT CRO55 ST. (This section-need not be tompleted if the permit is for one - - ��- - / ���-�-- -����- ......___. �d_� a55ES50R .--- ��--- �� - .-�-�-- ,. '� hundred dallars(§100)o�less.) -. - TRACT 4Z56H ��1 g�p�K LOi NO. 23 ,y,qp gppK�'•'- ' . FAGEI PARCEI, � ..,i : • • ..... TEL. � OWNER'' USEJ�O E MAP I certify ihot in ihe performance of Ihe work for whicli fhis - /���f NO. � ���'3c�� NO perm�t�s issued,I shall,na�employ any peaon in any manne� _.., , -� -A .- - SPECIAL�--- - �-- -�----� -� �----- - ' 'Y sa oi to bewme subjett fo ihe Workers'Compensation Laws. -�- ADoaESS- - -- � � - - -�----- �-� v-Qi'P'r� �pND�TiONS J � �:a _,;. , .., . ..• . + ., ;., :.... 9262 � ;u arY Costa Mesa CA z�P -- -�� J , Date,�.. ... �. APPlicant ..�. ., .�, '.'__._ _ _ . , . . __._ . .. _ .�� ! TICE TO APPIICANT•If;-.ofter moking this Certificofe af ARCHITECi OR � TEL _ DISTRICf__ CRO�P ttPE ' __ ..FlRE PRCC.ESSED 6Y ►- l mption,��you should become s�bjecf�lo�Ihe Warkers' ENG�NEER NO. ' CONS�/� ZONE Compenwiion provisions of the Labor-Code,you must forih- .p � py '� i uVi wi�h comply wilh such provisions.or�ihis ADDRESS ..�___....._. _�, ._, . .permit shall be--_.. _ _.._.. . . .� . deemed revoked_ .•.; � � � . . . � ; . . TEl j STATISTICAL C1A551FICATION � APT. CONDO��� CONTRAC70R ' NO. - ' �? UCENSED CONiRACTORS DECIARATION � , � �"" -" - " �� � �' - �- __. ' ".__ ._____ ._._. ._ '. . .__._ UC.._.__ �._.__ QASSNO.�LDWELL UNITS ` 1 here6y affirm ihal I am licensed under provisions of Chapter 9 pDDRE55 � NO. (commencing with Section 700D)of Dwision 3 of Ihe Business and .___. . _-_ - - _- ---' ---"_ ..---l�C._-__' � ��R� . ., � - - _ nd my license is m full force and,effecr. ❑tt COStd M@Sa C{� CLnSS B � � - � -- ����� �' �-- -- - ���------ ,_.. � . .�.. ,J ..�: . r. . .. ..,.� ..� .. � BK. PG. ; . _..__ 5�.FT._ NO.Of._.. __. NO.OF___ CHECK : -„., n_ _.� i Rofeuions Code,a VALIDATION LicenseNumber 4096�0 •� tic.Class ' R' ' Stze- sroeies FAMILIES ��ONE � � V . .. , .. ..: - � .,. � � � , i . . . �. .�,. �j , ...._VALUATION_. _'..___._; � I am Bxgm a und Fi$BCCa��f' .. _ ._ OESCRIPTI �WORK--PLAN 24'�... . . "-- A D� _Q .I e J�'' ' Contraclor - Dme � �S J i! �0 a �--- -- a L� � . . . Y '�f7�2���- ❑ P - ...� : � � :- ALTER ' • . , . .. ..,� .... :.., : � .... .... . . . .". . , ❑ . � , � �_ . ... B.BP.C.fOr ihis reason _. REPAIR-Q "'S -.-•-. _.. :. ._. :..._ _ _.•.�_J:+.,�,(}L o-. . __ ... _ . ... ate ... �.�. USE OF � 1 .-___..__ ..�-�.'�,2��'_�fJ..._. '._.. Ex15TING BLDG. DEMOI ❑ ...�.- Signafu�e �� � " - � APPIICANT iEL ' ; WNER-BU DER DECLA ATION PR�NT NO. � F�NA� g 0/� � ; I ... .. _... .. .--� -- -- �-- -- . ' ..- -, --DATE.'. �.I 1'1---... --- � ....�_.— ----._:.._.....; �-I heraby aiiirm that I am exempt from�he Contractor's license � ADDaE55 3151 Ai rway Ave.�N, Costa Mesa � .., - � ,r.:,, Law for the(ollowing reoson(Section 7031.5,Business and fINAL'' -- '���� � � ..._.... ._. ._ ..._...._...--' ".. ._... ��'Professions Code):" pRE N . --8y- � . . - _ � �,� 1, as owner of the properly, or my employees wi�h qpp0 55 � �� _ _ �..._ . . . ._'__. .. . -'.. ___._ . . ._ .... ... . .._. i ' _".. . .._ _ -__ wages os Iheir sole compensarion,w II do Ihe work and - - the structure is not intended or offered for sole(SeUion loCnurv � � f � '�-- 7044,�Business and Professions Code -- �� - - ,-_ - ��� . _._... -�. ... ` C oA )...'. __.' _ '.'__.. MOVING .. _.__._ ._. _ _. . . ._.._. TEL."' ' fr • � e • _ r�i I,as owner of fhe property,am eaclusrvely conlracling CONiRAQOR NO. '� .-� " .; ',•��,�0 O a•a -'wilh licensed con�mctors to construd ihe projact��5ec-- '- -- - . ....._ .-..--� ----. ...---- -----_ . .__ - ._. .. . . . _ . . . _ ---- _ .. -' , �iOn 7044,8usiness and Proiessions Code). /+DDRE55 � � - -��- o � .REqUIRE� . TOTAI SEiBACK f � 5�e G O a�� -�- ""���--"CONSiRUCTION LENDING AGENCY--`� "� '" ' -' �vARo HWY- � � - ��� �--� - - -- � ,-� � � _ ._ _ ._. SETBACK PROP.LINE WI�TH �- :'• I hereby affirm Ihal lhere is o wnstruction lending agency for FRONT �, ' � � � O Fy 2 O�II� �� : - the performanca of the work forwhich�his permit is issued --`- --v.l- ----. _....-- �- �---- --' .._. _.,._ .....--�- -------._--.-_.--..-_.-__..�.__---. _. . _ _._.._.._ ._ ._._...__; (Sec.3097.Civ.C.)• SiDE � . ' .:..,. . , ! ^m .._ ..._. .. . _ .__.. P.L ' ��-j � ,.�,.,.,,�•��"i � - Toronto Dominion Bank� -- � Lender'sNome -�--�-------- .__._... ..--�---1---�--'--. ._., $ _.149.Sansome St.,_.Sui te 700 / �[�']y �o^�,RaF.� •' . -'"' `-- -� �- P.C.-FeeS - . ../OZ� PermirFae' `�+ /-/•.�'-'' - Lender's Address • � " -- - - � ' ' - '- � -- ' � -7 ' ; ' � _.1 certify Ihat 1 have read this applicoiion ond siate ihot the _..._.__ .. . ..- _-_/S-(/�-__ issuooce F�s - -/�'-�� .. -IDMA V/C M-___..__. . � . . _ _!.- - _' - -^ a abova information is correct.I agree to comply with oll County inves�igoiion Fee ' � __ordinances and Sta(e laws relp�ing_to 6uilding construction, _..,_,.. .. �� �O I � . - � ... _'"' _ '__ .__".. . To�al Fea._ •.. ." IDAAH Perm.M-..._.. ..... ' '�.: u and hereby aulhorize r prese iativ of this Counry to enter - - � - � upon�h b •me f' ned p p rt f r inspection purpos}e) - / �: ' g �--- - /��J �,] -�--- . . _ _ , r` r - --... _ ' --////'' - q� �-- --� __ -- � ./�� ����` SEE REYERSE FOR E7(PLANATOaY IANGUAGE ' - - Signature of App ca ar A m C(�J�L_'_' . � • � i � 9 . _ ._'. ._-Daia- .... _ _ ._'-__'_ _.._._ - ' i ' ' . . .. _. _ .._.."_""'. .._�_..__ _' ___. ._ ._... . � •I._-" "- . .'�QQI � ; ; = ; '� . �. <:. . Y ,L - 1' � \:' c „�_.'�,,.0, � � • _, , ',t � __ " - :i • 4 �U uC7•C ',..,.✓1 Y�- .. . . . �- � ' �-'�^`p','~ 'CJ �i.�C-,� .Cr:, � � - :,< � � . 4 � ' ' � � � ��:CI-�y C���-y �' ` C O.i C L.� � �m �`� � ;�' . . �S �.eT V.� C��,N.^.. 6 ►. TO 4 � 'Z ! m �/! ' � ' . _ �'• ' �n. ..t',u C "v�.•"^C.' C1�O y,S ,,,�� p�'r � ��'^.� �* �., , _ O ' . r . . ' �'. � " ' �' �C��..4` .. . C �.. ` � . N �, cpL"� � 1: % \ n :,•V.V °'n'r p.� a� G� � V,-4 �.at c`^=' .•C� � �" "'S. .. 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