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' 1NORKERS'COMPENSATIONDECLltRATION ' . � ��'••'. ' � '.` '! � . •
I hr.reby o{�;;m,�a„�a�e o�e,,;�;��,�a<<o�=e�„o,e�F � - �� � �APPLICATION� FOR:BUILDING��PERMIT �-���;
insvre,or o crr�iFicaie of Vlorkeri Compr.nsation Insuroncc,
or a cr.r�ifir.d copy ihereof(Sec.3A00,La6.C.)� � � � � " ' � �
COUNTY OF LOS ANGELES BUILDING AND SAfETY
PolityNo�jj��ompc�lYf�l1S Tn3am.,;ry f'n, �
� Ceniiir.d copy is hereby furnishr.d. FOR APPLICANT TO FILL IN BUILD:NG �i f ni,2
noosEss �CJ ,
� Cerlificd co�y is filr.�1 wilh Ihr. oumy buildi nsp !!UitD!NG ( •
Iio deparlmenl: � nDo?E55 SC. IVeS Ct. �0�•
Do�e � pplicant ' ' CitY Dianon� Bar Z�p �p�q�ITY
� C TIFIC E OF E%EMPTION FROM W KERS' ' - " ' "' ' NO.OF�lDGS. NFAREST ... ... _ ...._... .__ _. _
� COMFENSA710N�NSURANCE � � S12E OF 10T NOYJ ON LOT CRO55 ST.
(This seclion need noi be compleir.d if the permi�is for onr, TRnR IlIOCK LOT . 14 �AP BOOK ' � � PAGE PARCEL�
hundred dollars(SI00�or less.� ..
zlif. Commtmities Inc'E� —3700 115E1CNE h+�P ���.. 3,�
I certify thal in ihn,performence oi Ihe work!or whith 1hi5 DWhFG� NO. ��� �. } I
permil is issved,I shall not r.mploy eny person in any manner ADC4ESS31H� A A1CW1 AVCilUC ��� , ���' S7ECIAL � � ��-�� �� � �� 6.
so as�o becomr.subject to�he Warkeri Compensa�ion Laws. O COnoiTiOvS � O
arr. Costa Piesa 92626 ._._ �+
, . . . . . ... ... ZIP . pC
Dofe ' ApPlicanl ARCHIiECTOR TE. O I
''�ICE TO APPIICANT: If, oftcr�moking Ihis Cerliiicolc of Aram IIasenian .o:siR�cr GROUP ttPE .. FIRE PROCESSEU BY . F
ENGINEER NO.
� ; ption, you should becomr, subjoct �o ihc Workers' " — 9 ,p CO� �ONE W
��mpenso�ion provisions of�hr.Lobo�Code,you musr fonh- p;Eu3�90 S•:esterl• Pl. i�1�0, ;;.B.92660 /d. '✓�''J � ... �J ..� . .a
wilh comply wilh such provisions or Ihis permil shall be � �V �n
deemed revoked. � . TE�� S1AiISTIfAI CLA 7FI[ATION APT. CONDp. Z .
CONTRACTCR NO. -�-.1
LICENSED CONTRACTORS DECLARATION . � � � � � � -�-� ���_ nn55 NO. D`xELL.UNrtS�L
1 here6y aliirm ihal l vm li�ensed under provisions of Chaprr.r 9 ADDRESS No393701
(commencing with Sea�on 7000)oI Division 3 of the 6ustn=ss nnd _ . . . . __ . _ _ . . ,.�i�_ . SEvv�R�1nP
Proiessions Codr.,ond my license is in fu�l force and efiecL C1n55 B 1 �� PC_ � �:�". " ' VALIDATION � �
5 . ,. NO.OF NO.OF CHECK .
license Number�,93z(�7 ` (iC•Closs � � STOR'ES FAMI�iES Oh'� � �� 6��j I�
� VALUATION . •
' �' ' CFSCRICTION CF Y/07K
NEW
�,�_ � " - s202,900.00
Coniracl � I Dale ADD � i:• e o •C�
I om exem t nder See. $.F.D. — P11n 4 p�7FR
❑ P � � � f •fiG0.70
0.8P.C. r his a5on REPAIR � S . . . ' ' � ' — '
USE OF
^:?GG.70_s .
Da!e: EXISTiNG OIDG. CEA!Ol ❑ ,
� Signoturr. APMICANi 1CL. FINAL C:C,C J r II�
OWNER�6UIt DE ARATION I�i!�1) NO.G6Z-3�0O . DATE-��� -���-� � �•�� - �� -
� t hereby oifirm that I am eae t lrom tho Controcbr's license �� � V�v' v�
low for Ihe following reaso [Scclion 7031.5,Business and ADDRE55 E�' 3 flV . C.Tt. 92E12�7 RNAL' • _
Profr.ssi6ns Codc): '"' ' � " �" " �� � �� YVCSEN7 SY �� �/ti:� � "
^ P.UiIDING ' . .
� I, as ownr.r of thr. properfy, or my r,mploye.�s with ADD4E55 :_� �.G F�!�
1 wag�s es iheir sol�ccmper.saicn,will do tho work and . '" .
' thc structure is no�intended or offcred ior sale(SeUion ����TY , � �+e.e • �
704E,6usiness and Professions Code). ' ' "� N.OVING � - . TEt. � � � � _, � � � � �
CONTRACTOR NO.
� 1,os awne�of Ihe proPPrly,am r.Mclusively con�racling . . . .:. . ' . . , '•� "�)L,O G
with licensed conlractors to conslruct the project(Sr.c- pDDRE55
tion 7044,6�siness and Professions CodeJ. ' ' �� • e�:i 2.[�i U u
� � CONSTRUCTION IENDING AGENCY " SEj�gA�� YARD HV/V TV�ApR�pfp�INEfRU.N �,yiU�H
I hereby affirm ihat�herr.is a construUion lending oqency for taONl G�.�G�—��i
the perform�nce of Ihr.work(or which Ihis pr.rmit is issued -� �� P.l. �� � - .
(Sec.3097,Civ.C.�. SiDE
. P.L ._ .. . ... . . .
Lender's Nome �[— (J .
. . . P.0 Fee 5 V OD�7� � � Pe.mu Frc� d I.� LD'M Ref.A . .
lender's Address p .y�- �( '
I tertify that I have read this applicotion and stare thol�he . . .F�t ,�c /J•�"y � issua�ce Fe� - �•� t�MA PiC M , � � � �
obov informolio ' . ct.I agree�o com�ly wilh nll County Invesiiga��on Fee p q .
or ino tes an Stale .Ia'' � ildin9 conshuctian. . . .. . . . . . To�vl Fex-" 'JSeC•� ' LD.UA Perm.q . . . � �
he by au h e rppr, ntotives of thi ounty lo enlcr ' � . �.
u t �v .�oned p opr.rty f�ms ctio purpnses. .. _. . . ._. ,/�A� .. ' . -'': :� . ' '.
� SEE REVERSE FOR E%PLANATORY�GAUAGE ��
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