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0930A 0931A
� . � � WORKERS'COMPENSATION DECLARATION .... . . _. _ .- ..--"--...._.�_.... _ :.._._._.. .... . _._.. .�.-- - - '_'-.__.. _ _ . �, �6 . I hereby offirm tha�I have a te.tificate oF�o�;e�„e s��f �qpp��CATIOIv--FOR-BUILDING �PERMIT �. � insvre,or a certificate of Workers'Compensation Insurante or a certi� 'o thereof(Sec.3800,106.C.). . ... � '-----'- -.. -. .- -� - - - y-- - - -' - � . I ���(7993 ... . _. ... _ ,._..., °' UNTY OF LOS ANGELES BUfLDfNG AND SAFETY . : _ , vou�,.r,a. com��;, Hartford'Group _ , . _ _ . _ Certi(ied co ishereb furnished. ' ,.� ��� , BUILDING � 0 PY Y FOR APPLICANT TO`FILL IN ADDRESS �D� • � yZp„��,. � Cerrihed'copy is iJed wiih.lhe count building'tnspeo- �-��-' BURowG � � . ��fion deparfinenl. ` '-.� ADDRESS 1029 South Lon ' � 3 ' � - � ..�/f : � � __ .. _... _..__ . � �ate � ��—o.ry,PPlicant. . . � UTV ' ZIP -- -- : IOCALIN • � ''CERTIFICATE,OF EXE/v1PTION FROM WORKERS' ` � � ' ��� � -- �----- �-NO:OF BtDGS.-- - �--- -� niE.4aE5T .... . - � ' '� COMPENSATION INSURANCE -��- •� � SIZE OF LOT NOw ON LOT � CRO55 ST ., .. � � � � � ' .,.' �.: �.. (This seclion�need not be completed if Ihe permit�is for one ��� --" TRACT � �BLOCK lOT NO � " "�''� AUE550R... � .--. �. , hundred dollars(SI00)or less.) . � ., . _ , MAP BOdC �" PAGE� PARCEI ... . , � ,. . ,.._, TEL. . . . . . .,,. ..,. _.. '" '. .. U���E MAP I certify that in the�performante of the work for whicb this �NE� "-'NO.--- _ � ' � . permi�is issoed,I shall nol employ any person in ony manner ._. A�RE� 3�5�.,A1 PWAy-�AV2. -SU�te-N'' r�� S��IA�� �O so as to bBcome subject to the Workers'Compensallon Lows. � �'-� �- rT?�"f' CONDITIONS � � .. ., . :�. . .. .� . . . ..; � V • , arr_.._Costa_Mesa, �a---.nr.._...92626 - __ . _..... -- ._ _ . .. . ... _. _: ._ ;m Dafe � --. .. .APPlicanY.. :. . ...,. _. _. ... ' ARCHITER OR ��, � ' ' ,�� 1 ICE TO APPIICANT:�If'offer'makmg'this�Cerlificole of _�ISTRICT . GROUP. TYPE. , FlRE . PROCESSEDBY_.. . Q I - jn'plion,�yau'ihould bemme su6�ecf to��Ifie Workers' � �--- ENGWEER ' �� - I /J �pN E . ��j Compensotion provisions of�he lebor Code;you musf(orth- qDORE55 • rC�__ '1'3 � �� �"'r � •W with com I wifh�such .- .. ...'-- - ...... . . __._ . .i a Y P ermit shall he . .... . LICENSED CONTRACTORS DECLARATI TE�' STATiStiCnl CL455iFICATION ; � AVT. CONDO. . .Z I hereb oifi�m thot I om licensed under rowsio CONTRAROR B m ' No. _ _ , ___.. .__..__ _ _ _ p y provisions or t is p deemed�evoked.� . � .� ON�. � ___ ._.._.'_ . .. ..__. _ .. . LIC.- .._.. ..._ .. CLASSNO. �� DWEILUNITS� ..._ .. _'-' . " nsofGhaprer9 ADDRE55 3151��Airwa Ave.,NNo. 409610 " � (mmmenting with Settion 7000)of Division 3 of ihe Buziness ond _. __ ____ � . SEWFR MAP � • � � � Y . �,. � .. ,� -.. ... _ .. .". "._' . . _ _ l�,__:.. ..._._. . Professions Code,ond m license is n`fc�IClass"and effect. �i7y C�� ' -'.- ._- .. ... .. . ... . ... ..... ._ - . � . .. . . .� gK. p�. . ' �VALIDATION-� -'". ' . , � � � , _. SQ.FT. ,_, NO.OF_ _ NO.OF CHECK„� I � . ,, ..: UcenseNumber an9Fi1(1 �B � SIZE STORIES FAMItlES. ONE i •. . • � .. . - ' �� - . -'- [ ._.VALUA710N, �<�C�'3��1 Conr�ocro� Rrama 1 aa fa 1 i f Dafe � � � - DESCRIP N F WORK'-'- ' ��---- N� / ' " • ADD g S /� � ' r, °- �d � ��� �. ❑I am exempt under Sec. - -S1 fl �2-FArll� -R l d --- --- , - " � .'."_' . . .. .. ,. ' ' ALTER 1 I e����,� O'. � - "I'_.' REFAIR-� � f _.. ........_....'___. ..._ . B.BP.C.for this reason N@W Constructi on ------- - ----. --- - _ ; _., r . .__. -_.._.. .. _.... _.. � � �" USE OF , y ���i" '_ � - Dale:- -�� Ex15TING BLDG. NOIIE DEMOL ❑ ' ' , I' �'�' ! . _'__.. . ._'_ . .__ — ' .._ . Signat'vre ` ' � APpItcANT TEI. : FINAL �)/ / �£��i OWNE -BUIIDER DECIARATlO PRiNT 20T' e Vedel l NO. _ : , r�'6 . .__.. -- ---- - � . ...DATE-.7 �_ �..'�--• — ---^. .___.. _.. -�I hereby affi�m ihat I am exempt from iha CoMractor i License � - -�--- Law for the follawing reason(Sectlon 7031.5,B�siness ond AooRE55 � � flNAL � �� � • ' - � � ._ ._. ___ � �' ---- -- �., "'Professions C6deJi� - - � aRESENi B - -�- - - �.. 3 BUILDING i ' �,�� rt . I, as owner of the properfy, or my employees witb ADDRE55 � . �(} �y - � � wages cs their sole compensation,will do tha work anJ ��-�- - �-� - -- - �- � the atructure is no�in�ended or offered for sole(Section ����TY � � , --'- i!e e e e o�� - -- '---'-'-... . ....... . ...... -- ---... _ , --7044,BusinessondProfesslonsCode):- -- - ���� MOviNG�--------- --'-TE[.-�-- � - -- - .--.- - - _-. f �,as owner of the properly,am ezclusively coMrocting GOMRAfTOR NO. - ' . ( e b Jr�,�C _.�...with licensed contratton to conshuce the project(Seo- . . ._. ..-. .._ . ___. __.._.._. . -'-.- ---..--- . . ---- ' --,-- -... _ . � . -' tian 70C4,Business ond Pro(essions Code). ADDRESS � ' ,, U�,� �, c' --"- --' .RE�UIRED.. .._TOTALSETBACKFROM._. . I .. . .._... _._.. ' '''_ ' '�' "',- ^ � • ,� ���CONSTRUCTIONLENDING�AGENCY"-" � � ' SEienCK YARD- -Hw�'- vROv.twE wiDTrf '� -- � -' I hereby offiim�hat�here is a constrotlion lending ogency for {RONT ' � � O�f.'O�E�C] � -� 1he�performance of ihe wark for which Ihis permil ie issved . .. - .._P.Lr----- ------� ---�---. -.. . .._.----... - .--- .- _: _.......- -'--. -'- _-... �--�-.-,. --i - � .• (Sec.3097,Civ.C.)• SIDE , . . .....� .�:_ .. , ._.'_'_ P.L._ ._...... .... ........ .. : .;� , t�..�. _ ...._. _._ . . . .. ....__.. ___ .. . . . � lender's Name ' ' '. . ._.._._—...._._....._ . ...,.'r '. __. __. _ _.. � �, . . .. ,! ......,� {.,• ' . IDMA Rei.N � � .. .•_ ,�' . - - 144 Sansome 5t. S -.._ P.cFe�a---� •S/ - r�,m�Fe�--- �T7J __ __ _ _. lender's Address pn �+pI1�^1C a Ul t2���� � . � , ,, -I.certify ihot I huv TABd tnlStlppliC�f�A a st . ihe .__-. _.__ _ '�'_' J r/'])_ . Ivuvnce Fee� -��-��V�-'-� lDA4A P/C A...--�-----.._-_ ''- -.____ ", ..,'� ` obove informofion is mrretl.I agree fo mmply wifh all Coonty Invesngotion Fee � � ,_ordinances and.5to�e laws relot(ng to building_mnshuction, ; .,. ,; ,. . '� . _ _....._...""'.._. __._`___-_. ToiolFee- . .�_.._� 'IDI.AA�Perm.N- ._._._ .. .'__..,__._ _.__'. �. .. . and hereby oulhorize representolives of this Coomy to emer � ' --- up he ob e-menf'oned pro �,J for Inspection purposes.� � _ . � � �,��� : _ . . - -�- - .. . . - - --. .. .. . _.._ � . � SEE REVERSE FOR E%PLANATORY IANGOAGE � � - � 3 _. .. . �g ure c ,r ge� . .... .. .pare._ .._ .._.__ ' —''._ _. __._.._ .._....-' _'' _ _". ._._._ I_._.. ._ '__. ____' ... .... ._. . _._. . . "'._. . 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