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, inzure,or a te�ti('cole of Workers'ICompensoiion Insura seli . ...�. ..'." . '.�. .: �;� ' . . ...Y �-�_ . �..__.-_......"'•"-" =,. - - . '-;-....,._. ..""'-'_- :-.',�� WORKERS'COMPENSATION DECIARATION . � I�hereb off'rm tha�I have a certificate of tonsent to � _ APPLICATION��FOR�BUILDING-PERMIT�- �; . � nce ar a cer�ified copy thereof�Set.3800,�Lab.C:J �""-'� -"-- � -- - � - . COUNTY OF LOS ANGELES BUILDING AND SAFETY ' � � " Poi;�YNo.61WETX'79�3,,;Pe�,,Hartforii�Groua � ' --- --— ---..: _ . � CertiRed topy ii hereby fumished. , . ' . ', FOR APPLICANT TO FILL IN BUIIDING . ADDRESS �O �� Cedified copy is�filed wi�h IFe munty building inspeo- "'-" BURo�NG 'tion departmenf:- '.. . . .� . ADDRESS ], � . . ,��.- . '" ,. � .._.". _-__ _. ._.. .___ ___....___._ ._._'__..__._.. _. � Dale���� ���Applicant � CIN Diamo d ZIP tp���7y �1 ' -� CERTIFICATE OF EXEMPTION FROM WORKERS... . _...-�-- �`-------�._..... ....- .-- NO.OF elDGS... ...------. � NFqRE57 .__.�_ .____._. _ ._..._ ...-'.--'.. ..__.. ....-- COMPENSATION INSURANCE' ����'' ��� StZE OF LOT i NOW ON i0T -�� CROSS 5T._ •�., ...- � ��� (This section�need not be completed if the permit is for one -�--- � - --� '' --����� ��--��-��--�- --� --�-_��-- -- ASSESSOR . �- --�� -� -- �o� .. . -hvndred dollars(E100)or.less.) ,. . . TRACT �/ BtOCK LOT NO. � � M4p gOOK`�� � ' �PAGE� 7ARCEL �, � '� ' . . , TEI. I Certif�ihol in fh � ,���.` •.. . , . . ... . . ...._ OVJr7ER- ` .• � -�NO c ._' � � � U �NE NJ+F r y e performance of'fhe work for whith,this ,Ij NO i!l�� �,� � •-�: � permit is issued,I sholl no�employ any person�n ony monner _.__ A�aess$15].��Al t^Wd �AVf.-�Su i te N--- � - � oe - �'E�'"`` � � � - � � � � ��� } r so aslo bemme �ecl lo ihe Workeri Compensalion Laws. ' CONDITIONS � � __ ... � . ; . . . ..n. CITY._ _. ..._.ZIP. _ .._ . .._ . � __. _ . �. . . ' U 2 _ . .. . .._ _. _ . _. . .. � Dale� /O � �Appl�conf �. � � ARCHITECT OR 7E1. '� '1TICE TO APPLICANT If after"making 1hi3 CertifiCata of � • �� DISTRICT__ GROUP TYPE__._, FIRE PROCESSED BY _ o •� � � . ENGINEER A m NO.7�j2-1864 -� � py� - -- - - , -- I �nplion,`yoo shou�d become subject to the Worken' -�' - r C�//.; Zo�lE- � -`V wmpensatton provisions oflhe Labor Code,yoo mvst forth- ADDRE55 � � C� . �3 (/ -.-- ��l �++ wilh comply with svch provisions or ihis permil shall be'�-.- -.- . . � - � --- ��-�- - C. deemed revoked:. ��. '��. . . .. . - .,. _.,,,, • TE � STATISTICAL ClHSSIFICqT10N f APT. C DO. ' y cor�raAcroaBramalea Cdl�f. N�50-1001 /_� z - LICENSED CONTRACTORS DECtARATiON �� �- - -- .---..-. ., ... ._ ._.. ... . �"[�ASS NO. - � DWEIL UNITS� � UC: I hereby affirm that I am licensed under provislons oF Chople�9 ADDRE55 3151 Ai rwa Ave. N r,o.409610 (tommencing with Section 7000)of Division 9 of the Business and ___. _ ...... _ + . . . .. ._- .LIC. - - .. ��R MAP . � � . ofessions Code,ond my litense is in full fo�ce and effect. CITY EOSta M2S1. C.A CLA55 B ----------- -� � -�- -� -�--- � �-� � - �,' 409610• ' . ' - 54.�. f NO.OF NO..OF _ CHECK • `I Pr ; cenSeNumber '� L[�lass B '� SIZE� � STORIES � FAMILIES 1 ONE -'� B� , VAn^ PG. : : � � , . .,., ... �. / . VAWATJp�J._��._ �� �. ._ , . N' J V83dA . . � , �. � ..__... DESCRI TIONOFNJpRK "ZZCR'"/' -...-__.. __ .. � ramalea Calif:� � N� - � Contracto � Dafe ADp ❑ f ��� ' r�• • • .2� � �I am exempt under Sec: � . .,...: ----- � - � - � -' ----' ,��- -... . . . . � � � . . , ALTER � . I •2 S�L�J ::� . ., . . . _'__ . . .. � 6.8P.C.forlhis�eason 1' Ctl n REPAIR--� -...._---"'-._..' ...:-...- -... ._. . ____.. • ._ _. ...._"_. __ .. .. _p , .. ... . __."_ USE OF . : � � • w�O G O J�-� • Ex�ST�,,,�e�o�. none oenna ❑ . . _... -- --- n oL - ' Sianature L ---- �-- APPLICANT TEL : � ��� Y-U V � • OW�OECLARATION � PRIM Bruce L. Abb N0.85�-1��1 FINAL : . - --1 hereby affirm Ihat I am exempt from iha Controctor's License �. .. --�--'-' "..._.. .. . -�DATE -- '�L,..E�+--%. ..__,._..___'_'............._........_ Law for Ihe following reoson(SeUion 7031.5,Business and AD�RE55 3151 Airwa Ave. N Costa Mesa fINAL-��� -� ��� � - - - � . . ., . Y .__. _. _ . . .._ __ . . Professlons Coda): .--- _ _ . . . PaESENi e N, _ -�G£3 a j A _� euaoinic I, os owner of tha properfy, or my employees wilh ADDRE55 � J wogesoslheirsole�compensoiion,wilidotheworkand . , � • •-• • 1 ' Ihe stmcWra is not intended or offered for sale�Section ����T� � � � - • -'�- - 7044,8usinessand Professions Code):-._. ._--... _ -__. . MOVMG��-..._ - .. . �_.- ....--- �---TEt:.. ._ . __ . ,- ..-....... - .•! - ��4&t��Q I,os owner of 1he properly,om asdusively tontraning CONTRAROR NO. , �'� i , � � . i, -wilh litensed coMroctors to-consrruct the prolect(Sea-�� ADDRE55 - �. ..... ...... . .�--�-�--- � �--�-- ...-.....-': ' �— -. . -._-. -' . �--- .,- �-���+j�'�'S�� � tion 704d,Business and Prafessions Code). � � -� ! ., , , _._. ._'_'...CONSTRUCTION LENDING AGENCY- ._._ ---- -aeOwaeo._ YnaD_ �mn,. .i0ini SEtBncK Fe M xi . ___. --_.- �` �r;_ .. :. '�_ _.;._0$ � p_H 6 � . SET BACK PROP.lWE WIDTH I hereby affi�m Ihat�here is a construction lending agency for FROM � --� ' � � ' -Ihe perfo�monce oF�ha wo.k for which-fhis pe�mil is issued ......_.. . p.L- - .----... --'- ._. ...-'.-._...._.. ... . _ ___'- ---...._ .......... ..::: •_•_ ;-..�.... _ ($ec.3097.Civ.C.)• SIDE . -.� . . .. �� -- -- -Toronto Dominion Bank--- °L� • � ` �� Lander's Name [ . .. .._. .. .. ..._ --------' � . . .. ...... _ _ ansome . Ul B __... P.C.fee 5 �v�. - Permir Fee � .� ��Ref.N lende�'sAddress ��.q Fransisco, CA 94�na f - - : 1 tertify ihot I hava read this opplimtion and state thot the _. , tif .._ ..7S�UU-. _. Issuonce Fee-� � `d'S��-� �- LDMA P/L N- ..- ... ' `. � - ' � ' obove info�mation is mrrect.I agree to mmply with all Counry invesii alion Fee ' � � .ordinantes ond Sta�e laws relating ro building construc�ion, 9 � r-i� � i � ... �. � _ __.___ .._..-_____....__.'__'_'..___ Toral Fee-..._._ �'�U v__', .LDNIA Perm..lf-....._ . __-. .. . � ._� ond hereby authorize representatives of this Coonly to enter -"- �-- �--'-�'"' ���"�--�---- _upon the abovo-mentioned .ope y or inspeclion porposes. yd��}, �,�� .,,, i_ � . J � � .._ '.._... .__. ._ .. . . _ . ' //�', ..'�_._.._....._..__.. '_'. '___... _ �r . . . _'_ . .. -7�5�l% SEE REYERSE FOR EXPUNATORY IANGUAGE --' S naNreo4ApplicanlorAgen7_ .... . . pate__ ... . ..'_. _'_.__.... _..__"' "' ...... .. .. . . _.. .___"-" "" """"" ".'_' _.. . . .. 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