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. .,. . , . . --.. ...-- --� ..._ .__.....----_... .__.___..__ � _ __ ....._ ____. _ ._ ._._.._----- -- -- ---__. _. ---- , WORKERS COMPENSATIONDECLARATION "r-,'. ", ": •�; � ��•�,�,• _ - �, � � 7 � P , � . ,. . �, � I.hereby afhrm thaf I have o�e�„�,�a,a of tonsenf to 5e�f �-��� ��-���APPLICATION FOR�.BUILDING��-PERMIT� �� ���� insu�e or a cerlificole of Workers'Com ensation Insurance, � cbpy thereof(Sec:3600,ta6.C.) ' " "� �OUNTY OF LOS ANGELES ; BUILDING AND SAFETY � �' .. ' .. . - , or a cert��6 _ _ voi, No 61WETX799�om��Y Hartford G`ro�• ' ---- ---------- -- � Ce�tified copy is here6y furnlshed � FOR APPLICANT TO'FILL IN ADDRESS 0.�0 lhP.�.J— "'I�.�Certitied`copy is(iled withlhe tounty bui�ding Inipec- -'- BUiIDwG � t�;' J tion deparfinent. � .'. ...� . , �,�. A�DRESS � ' � i �(J )ate�� ' ' .. �'' .� ' . __ _ _ ___ . . _.... . _. __ , 7,r—s�Applicanl� � C�7Y � L7 tOCAtIiY � � �� CERTIFICATE OF EXEMPTION�FROM WORKERS �"'�. - - ..- -._ . _.----. .._--..'.'_. -NO:OF�BioGS.. ...�-..._.... , NEnREST �.._._,... . "-.-. -__--'.__.'.-------.._. ._. , � '• �� ��COMPENSATION INSURANCE ��'� �� S�ZE OF LOT / NOW ON LOT . CRO55 5T. . - ' This��sehion heed�not ba compkted if rhe peimil is for'one ---- -�---�---- ./, q55eS50R ,��--�-- -� - ��� . . . _. ._.._._........_.._. . . r.. ,:. : iondred dollars(EI00)or less.);..� . . ,. , TRACT � etoCK lOT NO. ' pqqp gppg-�•�' 7AG PARCEL ' :.: TEL U Z MAP �f ��certify lhat�in the performance of,Ihe work�for which�his -'-- OW�R - � -"�'�'N ' ���1 NO. 1'�3 j � ;r �ermit is issued,I shall not employ ony person in cny manner - SPEUnL•-- -- -� �- � . - �--�-� �� ---- � C. � :o az fo 6ecoma so6jecf lo Ihe Workers'comPe�Sar�o��aws. � Aooeess-3151-Ai rw � v .-Sui te�N�-� �-�-�-�-� 000D CONDITIONS • 'Q ' � .� ��: . : . � . . . � ....: . :.� U )afe.. ..". ' `� APPlicant„ ' � .,,,.. . .� _. CIN_C - ____..ZI ..'._-__. "' ._". _._'..__ �..___ _____ . . ._. _... . . ' TICE'TO APPIICANT: If, offer mokmg ihis'Certificdte of ARCHITECTOR � � , TEL OISTRICT_. GROUP TYPE, . FiRE_. ..PROCESSEDBY.. '0 I P _,_... ENGINEER AI'dm B 1 No. 52-1 ' - -" - � tion; you-shauld become�sub�ect•fo'�ihe�Workers /r �j �0 � i Z�E _,,.. ;{„� compeniation provisions of the Lobor'Code,-you musl forth- ADDRES�99 WQ terl P� 1 1 � - /�� — /�='�- ' �.( .�a vith comply wi�h such provisions or�this�permit shall be •---- '�"'� � " � -"�� � "�- - ';y leemed revoked.,� -_� �. ,. .. . �,, .- �„ . �,, • TE� �, sini�SnGaL CL455�FICAT�ON , aP�. coNDO:- ;,Z coNreAaoRBramalea Cdllf. No850-10 1 . -��-� ___ _____ ;— LICENSED CONiRACTORSDECLARATION• �- �-� �-�-�-�- �-�- �� �-�.--����-�-- - ----_.._.-.. "�yqSS NO. �•���� otvElL UNITS� hareby affirm thot I am licensed under provisions of Chopte�9 qDDRE55 3151 Ai rwa AVE'. N No409610 commenciog wifh Seqfon 7000J of Divisfon 3 of iFe Bosiness and .__... ���. __ SEwER Mnv • ,. - � �. � .._. _ ...._ .__... . Mofeisions Code,and my license is in full force and effecL GTY Costa Mesa, CQ. ��,qu B - -- -- . ---- - — � ' DATION'��- --� .. . . . . , , , .. . BK. PG. . ... . VAIi SO.Ff. NO.OF NO._OF CHECK � icen'se Number'409610 ' lic.Clesi B " s¢e " 57oRies FAMILIES � ONE i `-G�%.l U A � � . �. . . . . . , .� , �' Q . �V . ;. . :o�;�o�;o�_Bramal ea Cal i f po�e ` ,,: •, __� oeseR�c,�MOF WORK �. ..._. _ - NEW_ n __ TION��� �• e.�.�2, _ VA A � ADD x� s f:3 ; ]I am exempt under Se[. . . -- - -F • • "' ' - ALTER � . ,;.. - r °J s-�,�-Q._;.. . � . .,. ...... �. � � . ; . ____. B.BP.C.for this reasan ' � ��-S�� -'--'---� - '� - .. _._.y.s_, '—. RECAIR .. ..... -.._ . J E:L'��O-`u' : -��' USE OF � � . .. . . . .._......._.. _. .�� . �'Da1e:`- EXISTING BLDG. DEMOL ❑ � --.- O L � - � . _� / --.— 9 �S6 - S anatu LCI� ' T�'7/ '..-� APPLICANT TEL FINAL � OW ER-BUILDFR DECtARAilO PRINT NO _ r7 ' _. ..._ _ . ---DATE��-j.SCJ�c.s��-�� ..:�_... . .._._ ._ .. __-- �- � - - - I hereby affirm�hat 1 am exempf from 7he Contrucfor'z License qODRE55 3151 Ai rwa AVe. N C.OStd Mesa Law far the following'reason.(Sec�ion 7031.5,Business ond FINAL `' �' ���'�'"' � ' "��� � . B .. ./,. /J_ ---. _.. .___ /CXe[t - : - O�3 Professions Code): '���-� -'��---'-" "�-'- ' - -�' � pRE N y - � "� � � BUILDING C , • , n. , � I, as owner of�he property, or_my employees with aDDRE55 � - � � / wogesasfneirsolacompensmion,�wi�dorheworkond � ip�ptiN � , �' � ��� � � ��� j the strudure is nol intended or offered for sale(Section � - '� - � � � , �- - � 7044,BusinessandProfessionsCode):� �-�-�-�-- -� -� n�OwNG - �- � � � -�-� --TEt:--��--- �� � -- -� -- I]J�;OO'� � ' .O i,os owner o�1he p�operly,am exclusively contractinq CONiRAROR NO. � �, ^ � � - � � .. - �' P I I -.. . ADDRESS. . ..._..._ ._... _._ _ ._._. __.• __. "'_ _'."... ...�':�._..�__:.i,Z, .,,;_. .J-��l.O�� wiih licensed coniracton to mnsrroct the ro'ect Sec- � e�� 7 z..! tion 7044,Business and Professions Code�. . , . .__,..__'_"_ _"'_____ "". ..REOUIRED.. .YARD- HWY --iOiAl SEiBACK tR M I _".. ..._..._.. . ._'_.�_ '_ .,_ "_. '. .."(f � �j z.II G...^_� . CONSTRUCTION LENDING AGENCY SET BACK PROP.UNE WIDTH• R• I hereby afiirm�hot Ihere is a tonstruction lending agency(or FRONi � � "" � - -�haperformanceat��hework�lorwhichthis�permif�is�iesued -.- - -p.L-:---- .- .._ _... .. _.._._....-.--'- _._.. . _ � _.__ . - __ . � .:_� ..: - '. ._' _'._. -. (Sec.3097,Civ.C.). SiDE ,- . - --- - .._ .. _ _._ . _ . . .._... .P.L. , ' .�„���,. �, ......_. .. ._._ .. (ender i Name Toronto Domi ni on Bank -_._..__ ._..._ .. _.- --.--.-- . } �1erf� LDMA Ref.N ' •"�� � ._ . _.. _ ansome_St., U1 @. -_- p,GFeef' �7 :• 0 Pertnitfee F! ��.1.� LenderiAddress,��n Fr�qs,r156g� f� Q�_dlfla �y. ' ` . . . ..1 certify thatl hova read lhis applitation and efota that'the __... d-.d�✓f�j-.._... _L�--. Issvanm Fee- . IO r�--...� iDMA P/C# -� -'- --- -- ,. -. .� .. -- -.'- ..-'--- � obove iniormofion is mrtect.I agrea to comply with all Coonty Investigarlon Fee � . ��- � � _ordinances and S�ate laws�elo�ing to bulldin9 conslruUion, ___.__ �.� �, ,,- � �� _ _......_._.'.___. '_.'_ ..__'_ Toral Fee�-�- '�.-..... .LDNIA Perm:M..._ .... .. ... .__. ._..__ _ . _.. . .. .... ond hereby authorize representatives of this CouMy to enter ---- �� ' upon�he above-menlioned p o erly for inspetlian purposes. o �� � _ ` - - - -- __ . __ .__ ^._Q-___ ---- __ __ . ___ __ --__ �e-�-i� �3S -�- - . � J"(�S . SEE REVERSE FOR E%PIANATORY LANGUAGE � i � _._. . .SignaWreofApplicanlorAgent _. . _ .._.._Date._ . ._..__ ._-.. ....... ..... .. .... .. ......... ._...... .___ ._.... "._. . .':� � '. ' . ___ . �..�'., !,Qi -- Z ',o..; .� o .. ' Y�� `A Y o, �. ''� ` -c,- , .O- y� O � � N �.a o' o. .4 p t� 9 ` p v o o� ��� °,�,. � � � .t ? W .. . 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