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insure,or aOce tHica eOof Wo kera��,.. . , ._ "-'..- '--- - , . .. . __....._.__.,.� ......-':-• "'-•--_._.... ........rw'� -.-- '- "-"'-'_'-"."-- :.. . � . �� ' ON DECIARATION � �. �' .�. • •: . • � - � . ... . � ... ....�_.� . . . � _ ..._ . ._ f . .�.� � .I hereb affirm�ha�I have a certificole of,mnsent.to self � 'Compensalion��;��a��e, APPLICATION FOR-�BUILD(NG �PERMIT�"���-� ` or a ceitified coPY.theieof(Sec.3800,Lob.C.)� . . .- ....".._. _ ... . ' - . .. . , . . -„ - -- "--.. • '•� • COUNTY OF LOS ANGELES � BUILDING AND 5'AFETY � ,:; aou�,,r,o.61WETX799�om��YHartford Grou� - ' , ._ _ _. _. _ - -- � Certified copy is hereby fumished: � .!.�,.. ,'• FOR APPLICANT TQ'FILL IN qppRE55 •�O�3 • �l�IpA�r � .�Certified topy is�filed with the eounly 6uilding�inspeo ---. BUiLDwG , - �ion depdr+menr: � ADDRESS 1053 South Lon vi ew �3 , . , .;,. . ,. , .. � �r, . .� ,�, ..� .,..,, .,v�.,. .. -- G - ----- _. _� Date�-D�J.A'pplic6M aTvDiamond B nP ' �ov,uTr � � �, � � CERTIFICATEOFEXEMPTIONFROMWORKERS�'.`' .. . . . ....'... .. .. ...'........_.-�:Ofetoc5. -....-. --.-: nuqREST-- -........"'-'-'--.. - . "-.--.-'..'---y.... ..._._� �• � ' ' COMPENSATION INSURANCE � . � S2E OF LOT / NOW ON LOT CROSS ST. h�ndre�dollars 5100 orless.P_,:.. •, .P . � . � OWNEtBPaf118�2d L1IIl7ted- �No850-10 �1 �PB�K' �� �, 1-' �7AGE . � This seclion need not be com leted if Ihe ermit s for`ona ASSESSOR ( ) � . . Ui�f��E �,P //-3 I certi( Ihot In Ihe erformance of the wo�k for which this NO. ��� �� ��� �� I permit is issued,i shall not employ any person in on manner � � • ' �� - SVEC�n� ���-- -� �� �- ��- ��-�- � �� - 'a - as to become subject to tha Workers'Compensaf on LGws. � ADDRE55-3151 A1 PWd AVe.-�U 1 tQ-N-�-�---���--�' �DD(7 CONDITIONS ' � ' �O So .. _ E cNoa°RAramaBassenian ZlP No75221864 • 1- , . .. . • . .,. .. 9 . ,. ...,. . --- ...... .. .-� 'CONS � ' Z�( IE V �, i Date�. _.. � � �' APPlicanY - . . -.... .. ',OG ICE TO APPLICANT• If aNei mokm IhiS'Certificale of . OISTRICT__ GROVP TVPE _ __ FIRE _ _PROCESSEDBY_.. � I ' �pnon;'you should become subjed to'�he'Wo.kers' `jJ/ . :. �V Compensalion provisions of Ihe lober Cede,you musl forth- qDD'nE55 3990 Westerl P1 ace SUl t2 17� �� � �-3� --- ---�- /�f' W with�comply with�such pravisions or�this,perm t sholl be -�- TE� � � _ �� ` :� deemed revoked.: -. : . , �,+. �', CONieACiort BPdffld�Bd C.a�1 f. NO.H�JO-ZOO1 STATISTIfAI CLASSIFICATION � AVT. CON�O: Z ' - �r . _ _. - LICENSED CONTRACTORS DECIARATION �-. �.�'. � - ... . _. _ ____..._ __,__. . .__ ii� ___._.__ _., �NO.�DwEi��UNiiS�L � I hereby aifirm thot I am licensed�nder provisions of Chop�er 9 � q�DRESS 3151 Ai rwa AV2. N No. 409610 i (commencing with Section 7000)o(Division 3 of the Business ond ..__... .__ , �R�P • ' " � _. ... _ ._._ UC.-..__ ..... Professions Code,�and my license is in full forte ond effetl. ��7y Costa-Mesa, CQ. CLn55 B ------- - �� ---- - . � -- -- . ,. . . .. . : ..- ,. . ._ ... - ' .. . . ...VAI IDATION'� `��� litmseNumber 409610� � .�..:.i;�.ci,;s.. ....., . s'ze".1 84�� s"oR°s..-2��---F MNES�-��-�-� � CO EK..i BK. PG. - : , . ',. . p- '___ s . .� . . . . . . ' .. L�/,�. .-VAIUATION ' ^ �� , •. . � , . � , ` . .., _.. . OESCRIPTION OF y�ORK -"_ ._../ _-__ ryEy,r__.�i __...._. .;O LI A �: . � .. .. a_� i eom�oc+o� RramalPa Calif.'oare � � S /p/ 7fi�� - Sin le.Famil -Residence ---.. Aoo p _ _��_• • •2 j _; �I am ezempl under See. �-� - �-�--�-❑ ,�; � . . ALTER . � •- ,��' .. . , . . . . ... . , i : ' ... I.•J.C.O..4� �...� � "' .-'., . . . . . B.BP.C,for this reason New COIIStI'UCt10f1... .. _ pEpaut-� -S-- ---- '-- -- -- ` � _ .. _ . . . ._ . __ . .p � . � ` USEOF . . . e� _, ���. � EXISTING BLDG. OEMOL ❑ ._;. . .. , , [�LL-�-�_ �� S'enature � APa��ANT TE�� FINAI � OW ER BUIIDER DECLARATION PRiNT Bl'U N� - - .-,.DATE� - ��.� 9-�6 - - -- - ..�6�g7 -- --I hereby affirm tho�1 om azemp�from�he Contmcror s Licen¢e qDDRE55 3151 Ai rwa AV@. N COS td Mesa � � � - �. � Law far the fallowing reaion(Section 7031.5.8usiness and FINAL'` ` - ' ' '�'''+f ' ProfeisionsCode): - � -�--. _.._.. .__.-. _._- -- �- -- aeESeNr 0Y /�Itmp. . . 17_ _ _.__ BUIIDING __._.. .._. ._ _ ' �- ! I,us owner of�he property, or my employees with ADDRE55 � . � � wa9es os Iheir sole compensalion,will do Ihe work and � � . _ �� �h tha s�rotlure is nof infended or offered far sale(Secfion ����TY - . - � ' � ' I .-_. ..7044,BuSinessond Professions Code).. . . ..-' ''-� MOVING�------------'---- -TELr. ..-"....'-'-' ' . . ..---.. . .`� - r. s_a • • �' ! I,os owner of the property,am estivsively[onfracting tONTRAttOR NO. � �^ � � - : �, .�- wt�h licensed tontractors ro construct�he projeU(Seo -._. . ._...----..___._... -._-_--._____-.------.-._--.-.-._....: .-- - .._._ _.-.__._ .�_�. ' �_ . .. 1.e�4 9,��..--- � lion 7044,Business and Professions Code). ADDRE55 . . . ; : , REOUIRED . -YARD' 'HWY". . .TOIAlSETBACK R M.. _ %I .. ....... .......'___. _.. � �._._...'___. . .- {...�^_a.0 Q.9 O O�:� % - � �-�-���" --����CONSTRUGTION LENDING AGENCY-"-� "- - sei eacK PROP.LINE wioiri I hereby a}firm that ihere is a tonstr�c�ion lending agency/or fRONT � . � � " - --tha performonte af tha work for which�his permil-is Issued � �-��- �v.L�. ----�� ��--- -�-�--�-- �-'-•. .� --._ . .�-1_ �-�1 9-.g� , . _ ____. . .. ___ �..: (Set.3097,Civ.C.). SIDE _ � ' � - ' -_- � -- � _ r! . . i. . ."" '.. .. ._ '___ P.l.___._ . ..... .._.... .... . _ � ... ..._.._.......__..._'.:.__. :_ �, ' ..:.� ; �'.,..� . � __..__..'___._ �.._.. _...1 Lender'sNameToronto Dominion�Bank � - � � , � : ._ ,� 14 $dQ some. St. SUlt2. �.. �L s�J•�"� , �DMARef.M .,.• . . _. . ; . �L�� rI' CIS�S�Q C�- Q4IO4 �� P•C.FeeE--�ZO•T�-�- PermirFee � � � - ��-; �- Lender's Address a • . � .J cerf�f that I hove read this o licmion ond stote tNot tha . a �j ]S-c l�j� .� �. � ,-_. "` �.:�'.�:: Y� PP __. - _ ..Issuonce Fer.-.. D.• . _ .IDMA P/C N--�' -- -- . _.-'- . -.- . . . . .: . ..... . above informotion is corrett.I agrea�o tomply with all Counfy ���esiigation Fee � v : � '�� 'i . ardinances and S�ata�aws relating ro bullding construtlion, p (, � � --:.-� � . ..... Toral Fee- .. _/•� ..- `... .... ._ ___........__._._.._...'.'..'_' '__._.. .IDMA Perm:p._-_-___...__' ...;. and hereby au�horize represen�atives of this Covnty to enter � -� � -��-- ,� upon tha obove•mentione pro erly or inspection purposes. � . - -_ ._._._ ... -- - -- --- ---a7l�ry�-- �3.� . ---- -------- - _. _ ,,' = -� -- _- � ��6 SEE REVERSE FOR EXPUNATORY LANGUAGE � � " , _ - �2. �1�-�- ' -�--- Siqnoture ol Applimm or Agenr- - - -. -...pote . - ..'�-' ' - - -------- ------ � - .. ._.-----�---_ .. ...------'---._�-.: .--'... _..1.,.-'-._...__.._ _.lp•i � . a o , . �-- � _ .. ' T �_ O �1 r� _�.. -O" •�^,� O :� l .-N � p, o a Q 'S (, , ` '� ��.r. 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