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' WORKERS'CO'APENSATIONDECLARATION ������ '�" � � ' �' '
.. .. ......._.._ �. . .
1 hr.reby a{�;�m ihol I hove a certificaie of consen�fo s��F —-��1PPLICATION �F�OR �BUILDING PERMIT-- �� ���
insure,or o certifico�e of Wo�kr.rs'Compensation Insurnnce,
o�o certifirtd copy�he.reof(Sec.3800,lob.C.) ' ' � � ' � � -�� -
Poltc NoEC 860755FiCom COUNTY OF LOS ANGELES BUILDING AND SAFETY .
y PEqdus.. Indmni.ty Co.
� Cenifie.d copy is hcreby(urnished. OR APPLICANi TO FILL IN BVIIDING �� �/- N �p�.
ADOGCSS `W�l.'Q/
� Crriified copy is filed with t co��t hui � .. ec- A�IIDING
ito depa tmr.nt. ADDRE55 SC. Ives CT. � /,3
oa�e'� n�,�i�c�oi \ � arr Q ziv iaca.uTr
� C RTIFIC TE OF EXEMPTIO FROM 4KERS' "' "-"'" ' • ' '" ' " NO.CF 9LDGS. ' � �" NEAREST... �
�COMPENSATIDN INSURANC SIZE Of LOT NOW ON lpi CRO55 ST.
(This section�need no1 be mmpleted ii Ihe permit is for one �� ���- �- �-�-� - a55650R , � • � � . �
hundred dollors(SI00)or less.) TRACT 42566 � e�«K LOT k0. 15 I�Mp t30CK 7AGE PARCEL
o�vriraCalif. Comnunities IneNF< < use one mnr ���,�
I cer�ify ihct in�he performante of ihe work for wh�ch�h�s — ��/� NO. � � y
pr.rmit is issurd,I shail no�employ ony p�rson in ony mo��er AD'�RE55 31 HJ A A�YWiI ��VCRUC ���A�� n' �
so as ro 6ecome subject to the VJorkeri Compensation laws. � y �� ���� CONDITIONS Q
Do�e � Applicont • Ciiv Costn 4fesa ziP 92626 �� ' . " ��- ,- �
"'iTICE TO APPLICANT: IF, of�r.r moking th�s Cr.rtificole of ARCHiTFCT04 T��. _ D!SfRICT GROUP 1YPE . . FIRE PNOCESSfDBY � I
4n �ian, FNf,INFFR N� CONST ZOY ~
� p you should become sublect io the Workeri - ' i ` p . �U
tampensalion prowisions o(Ihe Labo�Code,you mus�forih- ;,DDRE5539�0 ���CSCCTl� Pl. :r 17D� N.T3 92660 (v. !C� � � P`Y y
wifh camply wilh such provisions or ihis permit shall be' 1E1. STATISTICAL C1A55'FICATION APT. CONDO.� y
deemrd revoked. . 2
CONTRACTOR NO.
IICENSEDCONTRACTORSDECIARATION � �� � � � �� � ii�, anSSNO.�DvvELL.UNiTS
I hereby aFfirm Ihal l am licensed undr.r provisions of Chopfer 9 AD�RE55 No. 393701 �
(camme.ncing wi�h Sr.c�Ion 7000)of Division 7 oi ihe Bus�ness and __ ._ _��� SEWCR NAa
Professions Code,ond my license is in full(orce and efiect. CiTY C�n55 B 1 �6K - � � - . "VALIDATION �
�] 19��_ 1�'O.OF NO.OF C�IECK , .
lkenicNumbr,r �q�7n1 Lic.Closs ` IZ 6 STOR!ES���� Z� FAMILIES 1 or.�e • � ,
• VAIUATION. : � ��,7 Fi
CFSCRIPTIOYOFYJORK ' � NF1J...� 169�9��.��
Con�ractar • Dolc � AOD � s �� T
�IameKr.mptunderSn.c. .S.F.D. —.Plan 1 .. . , � � � ��
ALTER � � e(.�1�,�I� .
B.SP.C. r his cason REPaIR.Q s ' "'"' � ' " '
� USE CF O ' • ���.7�^T:
F%IS7ING AIDG. DE.S'.OL _. .°�� . . -.
Si�nafure APPIIUNi �F�� FINAL U�.G�--E 6 .
JNE -8UI DER ECIARATION IPRINT� N� � DATE� �Z �C ... .. .. _. .. .
I hereby af(irm iha�1 om ez p�from the Contractor's license 92626 � � • � • •• � �
Law for ihe foilowing reas (Sectian 7031.5,Business and Aooaes�187A Airwav [�V2. C.Tt.• FINAI
P.ofessions Code): -� � " " Nkt n� BY `, �� � � �
^ BURDING . l �.. -. ..
1 I, ns owner oF the proprtrty, o�my employees wi�h noCaE55 '�� %�� (;�,-��1
�:•eges es fhcir so!c camper.sa:ion,will do the work and
Ihe struclure iz nol intendrd or of(ered for sale(Section ��`��TY , � • e . • � '
� 70E4,Business ond Pro(essions Code�. �- ' h�Ov:rlG - � � � �TEL. ' ' . � � -
� � : . -
:�... . . . '�.
� I,as owner of Ihe property,om eKclusively cantracting CC4TRACTCR NO. , . � � ;� � .
. � ��.QC
with licr.nsed tontrocto�s 10 constr�cl Ihe projr.ct(Sec- nDDRf55
lion 704E,8usiness and Professions Code). � ,�y a�i��
CONSTRUCTION LENDING AGENCY — .REOwaED fOIAI SkIBAIY.hNUM �xi .. . .. . .... . .
YARD HWY
SEI BACK FNO°.IINE WiDfH
I hr.reby affiim ihat there is a constr�cfion lendinp o9ency for kRUNI � ' . G�'.n��n�
the performonte of thr,work for whith lhis pe�mil is issued �� v.L - �• � -
(Sec.3097,Civ.C.J. SiDE - �
P.l.
Lendr.r's Nome FJ "
-7 / Z•S 7� lD!M ReF.M � ' '
.. . . . . .. P.C.fPP S ' �I•/ Pcrmii Fcrt�� �
lender's llddrr.ss �
I certify�ho�I hove rend 1hi5 opplitalion ond slata Ihat the . � _ �S�� Issua�c.Fen .����D IDMA P/CM � �
. _ .. ..... . . .._.. . . .
obove informotio �s corre . agreo lo[omply wiih all Counry in.esugo��nn Fec �
o�din�nces o�d tale �o building constr�clion, . _ . .. � To�ol Fee� ����"��O LDM,A Perm:N - 1� � -� �
he�eby auth ' reseni tiv o i Co�nty to en�er . �
u ff 6 vc- tionr.d pro .rty or in ctlio p�rpos 5. (��1 . ___.. ... . ... ^ _ .;... .. _.. . ' -.. . .
� - . � ... . . _ . .. . . �C"r7� �� • `.
��.�� ��� SEE REVERSE FOR E%PLANATORY L1INGUAGE
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