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0820A 0821A
„ . ., , _.... ..._ ... ._._ .._.._..._- _ .__....._.. _. _.__.__. ..___.�..__ _ y I here _WORKERS',COMPENSATION DECLARATION �'�'�' � � �'” ' " �='� - •`�� � 7 .. , , . . .... , ....... ......_. .. . - _ - . bY affrm thol I have a tertif¢ata of�o�5e��fo Se�f APPLICATION� FOR uBUILDING PERMIT �� . insu.e;or a certifim�e of Workers'Compensation Insurance . '' or o ceilified coPY.�hereof(Sec.3800:LaB.C.)'� '' � �-' .. ..'-�--.' . . .__ . _ _ . . . _. .-- -.--'. . . COUNTY OF LOS ANGELES BUILDING AND SAFE7Y aor�YNo.61WETX799�om��YHartford Grouo - - � - - --- - �q � Cerrified mpy'is hereby furnished. . FOR APPLICANT TO FILL IN nooaess f v f dY , � Certified copy is filed wi�h Ihe mUnty bvilding fndpec- '"�" BURDiNG v. '��tiondepartmenC�-��`"���� " �� " - ' /DDRESS 1041 South Lon view � � h�. � ' %Z�s�G - ..., � - QQQ��/���}.��' - _ _ Da�e�• � Appiicont. �^'{� CIN � ZIP � LOCALITV : � CERTIFICATE OF EXEMPitON fROM WORKERS'� '�'��� .-/ . ...._. .-.. ..-- -.--_..NO.OF BLDGS.- ---..... . NEAREST.__�_..-.-.._._. . ---.- - ' .... SIZE OF LOT : NOW ON LOT ` CRO55$T._ � � � •� � •'�COMPENSATION INSURANCE���' "� - - � Thfs'section need not be cori+ leled if tha ermit is for ona i � n55E550R.,. ���-����� ' � ' -� � � I P P . .__. . . ._. _ .... ._ . - - P BOO �' � .hundred dollars(SI00)or.le55.) .�.� TRACT �•I BLOCK l0T NO. 13 '% � Mq �� :PAGE PARCEL � K'. .. �, .„-� .� TEL � ow�.Ba•amalea-Limited-- - -- No850-1001 ����E �P 1 certify,thot in��he�periormante�of ihe work�ior wh(ch�this �� �, '�`3 � ' ' - � i} �permil is issued,I shall nvl employ ony persvn in any monner __. • • - ;- �j -- SPECIAL----- � -� .�� -��-�-� ��- - - �- � "d - so as to become su6jecr to rhe Woikers'Compensa�ion Laws. Aooeess- 3151 A1 Y`Wd -AVO.-St11 t2 N -------- .�-Ov0�J CONDITtONS � u -- Date_(�-l_AppLtont''. '� .. .. . .. ...,� -.__... CItt....COStd-M2Sd ..CA.. .....,zir 92626 .--- - -. -.__-� ._. _ ... _.._.._ -.--.. �ICE TO APPLICANT: If, affer ri�oking this Cerfificdfe of ARCHITEQOR TE�� DISTRICT GROUP1 ttFE_^___. _ � HRE_. 7ROCFSSED BY... .'� I � FNGMEER � NO. - �- �pN� ZD � �nption;�yoJ�should become sub�ect�lo the Workers' -�-�-- . . � // -�-'� - W Compensatton provisfons af�the Labor Code,yoo must foRh- ADDRESS ' � -_,"� a-__- R3 - /--� -- - � ' -- �� w��h�comply w��h-such provisions or �hu.permi� Shall ba'-�� -�- , � TEL.� STATISTICAlCLA551FICATION - '� AFT. CONDp.' IZ deemed revaked. • •, ,, cor�TRACTOR BY'dOld�2d Cal i f. No. 850-1001 - - -- " - -- - . .__... _ LICENSEDCONTRACTORS�ECIARATION_ �.� �� -� - - ----� ��-� � -•� --�-�-�-�-- -�----L1C:--- ---'-�--��-- Q/+uNO. DWELL.UNITS -. I hereby aHirm that I am licensed under provisions of Chap�er 9 ADDRE55 r10. ��R�p - :, , (mmmencing with Setlion 7000J of Divizlon 3 of the Bosiness and ' -- .•--.--- -_.__._._.....--'.- ---------------_IIC.-_.�._.-_'_' . ; ; ., �� .;. .._...''-.. Professions Code,ond my license is in full force and�effetl. Citt CLn55 : �-��-� BK. - �---("-�� . � �"VAL�DAT�ON"-""���--; UcenseNumber� anAF1�n � � � l�t Closs R � � �' �EFT. 5 OR�� �� F M��tIES�-1� - CONE � V � • � - 0 A - . ,,, . . , . . : .... AUATtON._ _. ._.� ... ' ..--- . �082 eo�r�o�ro�Bramalea Calif. po�e � " - ' DESCRiPTIOdo' K�`'T'25C -- -- "Ew � s /.�3� . -.,., ADD O • sY'�T . �t . . .._. _ .� ,.. � �I am eaempf vnder$ec. �' �"' - . . --._._.. . AL7ER Q - , ,� � •J��.� Q � �-� B.BP.C.forthisreason . . . .. .� ..�. .. . . N2W Construction aEpqiR..❑ -.s.-.. .- --- . _r. .-. _... .. --_--.`. .- --`-- ���'. .. ....... : . - .. . _.. _' _ . ___ _. _...._ ,...__._. ._., USEOF � � � � .-----4 �JG�.� Oc�. ; �� ' E%ISTING BLDG. I�O�I@ DEMOL ❑ ' . _..._ . _. __.__. . . . Q ytf/ ' _-. -.� APMICANT rE�. � FiNai , D 9 1 9-8 6 ........_S'9nalure- �. O NER-BUIIDER DECLARATION��_ ��NT� Na' - � _.DATE��� � ...- - - l ��7" �. ._,......._____._.._'•--"- .. _ .... _ . .... . _ . _ '•.., Iherebya(firm1ha11amexemptfromthaContractor'slicense A�DRE55 31�JI A1NWa aVC. N. COSta MeSd' FINAL���� '' " � � ' �` ��� ' Law for Ihe folloJ+ing�reason(Section 7031.5,Business and .� __�__. ' Professiohs Code�:._.. .''-"""' .. ..�. _�..�"" '-"" PRESENT . - BY .. . .(�� -. . ^ � - BUILDING , � . .... � .� �O�L.� ft �' �� _ � I, as owner of Ihe property, or my employees with ADDRE55 - �� ' �� wagea as fheir sole campensa�ion,will do tha work and --�� ����ry �, � �- ,} c _ .:�,_ the srrucrora is noi intended or oiiered for so�e(Settion � , - _ _.._ .-7044;Bosiness and Professions Code). ..- .. ---- MOV�NG-'---'- --.. . . . ..... _ .. TEt: -- - �--- ; ,'---- - �� � --6�� I,as owner of tha property,am axclusively tontracting CONTRACTOR NO. . ',� �_'- �1 ° �� � .❑ . . � ' _.. ' __ . - - wiih licensed�controdon to constroct the pro�ect��5eo- -� --- -...._. ...— .. - ----...--- _ ; _.... ._ -- - -��.;-- ..... o o�J�,Q(�Y' . tion 7044,Business and Professions Code). - AooaE55 � . , :: � __ _REQUIRED - �UTALSETBACKPNOM.. %I . __ __._____-.. ._____' '_ _..... ., _� ... . '.� ---�- - CONSTRUCTION LENDING AGENCY � ��� SET BACK YARD- MNY� � PROP.LWE WIDTH I hereby a�firm that thera is a construction lending agancy for �RONT . _ . C�8,,1 9�8 b.`.'. ��he performance�of the work for which this permit is issued-..... -Rt.-.— ..._.. ..--'.. -------------�-----` -'----'------._._ . �_._.-._ _...:_--'�'- .--_.. ... ....... :.' . (Sea 3097,Civ.C.J. � � SIDE . � _ _ .. ro�to �om��ion„B�nk ;� -- -- P.�. _ .. -- - - —__ - - --- — - Lender's Nome �S.��TC2�7II^� I �j,� �.� ' tohu aef.p � - . .-.-- -.- - i Lender'sAddressSaiiF'rans.i�sC�..:-CA:��94104 � -� �� P.e:F��s--.� /•'/C� '-" PermitFee '-'�'7 "� � - i _ ..I cerliiy that 1 hava.read this opplication and sfate that the __ - S'N�- �-- le�uonce Fee-- --•�-�u v-� -LDMA P/C*-.._- ' � '. � � � � -- .. ...._. . _._'.' '. ._ . � above information is correct.I agree lo comply with all Counly Inves�igaiion Fea � � � � ordinances and Stale laws relaling to building construcfion. ....... ..... . .... . '..___' --Toml Fee-. .- _��.� ---� -IDMA Perm.N ' � - - ' and hereby aolhorize representalives af this Counly to eMer - �, upon the above-mention pr p�rt for inspetllon purposes. _ . ,_ _ _ i _ __ _ . . �.. .-e��-r-�//_ - -- - - ---- oY d�v7yt-_�'`�S' /��Cf,�S4l�J SEE REVERSE FOR EXPLANATORY LANGl1AGE � ✓,i_YY � ��1 - ----SignotoreofAppii<onlorAgeoi -�- - .. .-.-OWe. ...'--_- '...-�- --'-- ��--. '-. -""--' --•.' � -� ______ _-__. ._ ___' . ' '_'_"""' .. . _. -_lOi ,.� � 'T! fl S O O 7 T Uf O N� '� �' N ' T'�' '�' _�" "�s "S" _ _ "' _" 2 � -�' C �o � N �- T � 3 °� ; f9 0 � �m ;:a o� o i� o �o- � ° ° � I � � � a �, � � �H a ,A C O � .�.� m �� �c p n.o D � O �O v �� � � 7' ! � f� T �? � o f � � a° � o ' ,°0 3�,'. : n� o � ° � � D� � 7 N Q O ' � 0 � { i W ��'� J V � 3 �p w ..� . �• � � I O O O � , O 0 ' "_ � `n � o' a « � v � 3 ° � O al � � �� ; �` .", m �o o, , o � �� - � `,7� -.f � , -.M , -, ° . c� (� !v . 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