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1179A 1180A (5)
. _ ._._. ._ __..._. . . . . . . ... � , . WORKERS'COMPENSATION DECLARATION � � � -- �. � - � � � I hereby oFf�.m ,�a�I have a cer�ificole ot�e�,e�.�0 SB�E � �- - APPLICATION � FOR BUILDING� PERMIT - � insura,or a certificate of Workeri Compensalion Insurance, or a rertified copy thereof(5ec.3800,Lab.G� COUNTY OF LOS ANGELES BUILDING•AND SAFETY voi�nrvo6lWBMX7 �mpany Hartford Group � Cart�fled copy ts here6y fvmished:. � FOR APPLICANT TO FILL IN BUItDING 24366�East Nan COUPt aooaess � Gerlified eopy f�filed wilh the tovnty 6uilding Indpao- �- eUi�oitvG Iion deportmeM. - nooRess 2�4366 East Nan COQPt oafa 7-74-R7 Appltcan�_BP81118�Ed Cd�lf_ C�tt D ' 1 z�a ioee�nv D.B. Hills � CERTIFICATE OF EXEMPTION FROM WORKERS' - - NO,OF BtDGS.- / NfAREST . . . � � � � �COMPENSATION INSURANCE �� � � � 5¢E OP tOT Now ON lor ! Ce055 S7. � �� � � (This section need nof 6e complafed if the permit is fOr One TRACT `tL�J7�J J BLOCK LOT NO.27 µqpsgppi('' � � PAGE PARCEt hondred dallars(SI00)or lezs.) ..... � TEL U ZONE� FMP � OWNER�� �� � - - NO. _ I i cenify that�in the performance of the work for whlch this y)J, NO. -.3 permil is issued,1 sholl not employ any person in any manncr . A�DREu 3],rjT A1 Y'Wdy.AV@.�.�N _ ��a- �CIAI . - . . . � - so os to become subject to the Woikers'Compensa�ion laws. COrvoinONS � oa+e apPrca�� cin COstd Mesd � zir 92626 � ARCHI7ER OR TEL. �TICE�TO APPLICANT: If, affer�making-fhis Cerfificale of ENGINEER Aram Bassenian No.752-1864 DISTRICT GROUP TYPE , FIRE PROCESSEDBY ' Q mplion, yov should become'subjecf�to"thr Worken' ,p CONS. � ZO U �ompansolion p�ovisions of tha Lobor Code,you must forth• ADORESS . �d_ . �/1'� � . W wiih comply wirh such•provisions or Ihia permil shall ba �� � �-� - � p.� deemed rewked. � . �� . � � .... . . ' STATISTICAL QASSIFlfATION APT. ONDO. N �� � CONTRACfOR �IB NO. �/ LICENSED CONTRACTORS DECLARATION . � � - -�--�- � �-- .. . . .. ��� ._ ... �QASS NO. � � DVJEtL.UNITS� 1 7 � �� � � z I hereby affirm ihat I am litensed under p�ovisions of Chap�er9 AODRE55 r,o. 409610 . (mmmmcing wiih Section 7000)of Division 3 of the Bvsiness ond . ..r . . . . ._�IC. ��R�'P Professions Code,and my license�s In full force ond effect Cltt :` cuss B - ---� - � � - � � � �� YALIDATION SQ.FT NO.OF NO.OF CMECK BK. PG. license Number 409610 (ia Class B SRE G- 'STORIES 2 FAMILIES 1 ONE - � � � VAWATION � Coniroclor OIB .. .� Date .�� . . _ �ESCRIVTIDN OF WORK - . . . . _.. . ._ NEVJ -� . s � _� . . ... �I am ezempf under Sec. . _ _ SFR A�D ❑ , �. .. . . . . . _ .. y: PLAN 24 A`TER ❑ 32� o B.BP.C.for thb reoson � � . REPAiR ❑ s � -- �� � �'9� � � � � � Date: - ' USE OF DEMOL - E%ISTING BIDG. ❑ .. . �{• •�2� � Signo�ure � p'P�pR TT Bramal ea Cal if. TE,,,o850-1001 FINAL . I �3 7 5 7 5 OWNER-BUILDER DECLARATION � OATE 3 ), .�� - . I hereby affirm�hai I am exempl from the CoMractor's Liteasa � 3],5],� A1 YW8 Ave. #N� Costa Mes - � �_ . o Low for Iha fol�owing reasen(Sectton 7031.5,Bustness and AODaESS y � FINAL' � �7�7 5 u Pro(essions Cade): � � � '� - � 6y � �- � , BUItDING Q�2$-C�.7 I, as owner of Iha property, or my employees wNb ADORE55 � wogea as thair sole tompensatton,will do the wo�k and � - `�iin, - tha srructure is na�fntended or offerad for sala(SeUion _. . _` . 7044,Business nnd Professlons Code).- - - - MOVING � �� - � TEL. � � � � � ' � � I,as owner of the property,am excl�sively centracting oNrtinROa NO. � . �� � $,Q A � with Iicensed contracro.s m conntruct rha project(Sec- A�DRESS . . .. . . ... . - � �. • . • • '('-�' lion 704l,8usiness and Professians Code). • • -REOUIRED .TOTAL SETBACK ' � ��� CONSTRUCTION IEN�ING AGENCY - - �� SEi gpCK YARD HWY p{tOP.LINE WIOTH 1 I •b�U 2 O O I hereby offirm ihat there Is a mnstruction lendtng agency for FRONT ,,s�� ' �he performonte of the work for whith this permit is iseued � - P.l. - � � - � ,' • e�[�Z Q Q�. . (Sec.3097,Civ.C.}. SIDE �,.., . Q a��-8 7 P.l. __. . . .. lender's Nome - San Franci sco CA P.e.Fes s Permil Fee IDAM Re/.M � "� lender's Address ' 75.oo , I certify�that I have reod thia applitation and sfate Ihat the . Issuence Fea lO.5O .IDMA P/C M � oliove informotion is mrrecl.I ogree lo comply wilh oll Coonly Inves�iga�ion fee - ordlnoncas and Siore laws reloting Io building consrruction, To�al Fee �.G z�.- IDMA Pe.m.M��� and hereby a thoriz �epre nlatives of this County lo enter � . upon b -men a raperty for inspaU' n p rpase:. . .. .. .. . �1 r -- . .. ., . . . , � SEE REVFRSE FOR EXPLANATORY LANGUAGE W - Sig aNre of Applimnl or Agenl. . . po . - . .. . .. - . . . . . � �_*+ ^2 0 0 .� '� � o in o . - o o n� T m �- -L� _-_ .-Z ,i- ---- � - c o . io o °c s T iD- 3 a-. = �� i�- p � n � m oi �a t' o jro ! . o � ;° ^� m �p �.: `�-' a o a. 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