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1094A 1118A
•�v�. .. _ . ' (�.bwNS'rr`-��: WORKERS'COMPENSATION DECLARATION � .. � C4 � � I hereby offirm�hai I hove a cenifica�e of consem to se�f � � APPLIC��g ��R. BUILDI NG PERMIT -� � � insure,or o cerlificale of Workeri Compensation Insurpnce, Y `��¢� or a cerlified copy thereof($et.3800,lob. .) •� COUf�FS�wF O AN LE BUILDING AND SAFETY Policy No. Company �'� � Certified cop is hereby furnished. _ F ��ANT r�,Fk�'�N BUIL�ING �� Cerlified mpy is filed wi�h tha coun�y building Inspec• - gwt�iNG �{,,�,^�7��M a 1 r'1'i '{ 'n�{ . C""" i �llen departmenl. � ADDRE55 �%"�11 M�1�iy�i y1i� �Y T.� E ' Dote �S' Applicont ~ �R tITY w��i l ZID IOCAIITY `I CERTIFICA E OF EXEMPTION FROM WORKERS' � - NO Of BtDGS. NEAREST COMPENSATION INSURANCE � SiZE OF�OT 3�.�3 S•F NOW ON LOT � CROSS ST. �This seclion need not be compleled if the pe�mit is for one ASSESSOR hundred dollcrs(5100)or less.) TRAR BLO�K lOT NO. MAP gppK�� PAGE PARCEL � uf TEI.•-\ ,ICL'luE µqP �p� I certify that�in�he performance of the work/or which this � O�'�NER .4�1�l�• NO. �2G�-Cl�(do �` 'i s � — � permil is Issved,1 shall not employ any parson in any monner ADDRE55 ��03�Z AF''7�V� SPECtAI t 1� �' so os fo becoma subject lo the Workers'Compensafion Lew�. � CONDITIONS lJ � � UTY C�R�GS ZIP �7�2 V Dafe• Applleanl - ' - LC NOTICE TO APPLICANT: If, ofler making�this Cerfificate of ARCHIIECiOR A � � TEL.Y.a �ISTRIC7 GROUP TYPE fIRE SSED B , ENGMEER NO. �S��LGYcYJ CONST. 20NE h� Ezemption, yo� should betome sub�ecl to the Workars' � - �? -�y-- . / V Compensation provisions of the Labor Code,yo�must/orfh• qpDRE55 '�[fD7 d."1"4-!Y��tT. 1.l94�C' C � I>" _!Lr'�N 3 W wl�h comply wilh such provisions or �his permil shcll be '.` A �y`� n. daemed revoked. CONTRACTOR V�J� 'Il 4 N0..7!'1� STATISTICAL CLASSIFICATION APT. CONDO. Z IICENSED CONTRACTORS DECLARATION ,j � ���,��Q�7� CL435 NO. z'�DWEIL.UNI75 I hereby affirm thot I am licensed under provisions of Chapier 9 nDDkE55 �O CO�tn� NO.l� (commencing wilh Secflon 7000)of Divisian 3 of iha Businass and . ���, ��R�P Professtons Code,and my licenee is in(ull forca and effect. Ciri �U,�''� MSS �� . . BK � VALIDATION �1 SO.FT. NO OF NO.Of CHECK License Num6er ��` ' Lic.Class� S12E �5�� S70RIE5 2 FAMiliES � ONE ` ���� N� ❑ VALUATION co�nac�o< <' ` Dale ^�(5'� DESCRIPTION OF WpRK Aoo � s (0 3,�3/ � � #�'� �9 2 3 �I am exempt under Sec. «�'ti" � A� , ' �X`�t� ALTER 8.8P.C.(o�this reoson �• REPAIR � � f ��!3���.9 3 � batey: �� USE OF y" �,�, `/ _ exisnNc eioc. ��`�"c�e��Cr DEhtOL � . .3 1 4,9,3� sy�amre �•.•� APPIPRIMT �ieta�ia,v�R No.rZ-ftS- oaiE� � ,��YC . �a p s 8 9 OWN - IIDERDECLAR ION � ,I hereby offirm that I nm eiempt(rom the Contractor's License JX����T1C �`����! law for the following reason(Sec�ion 7031.5, Business and aDDaE55 Cl�.�a' FINAL Profeuions Cade)� pkE rvi gY � - ❑ 6WLDING I, os owner of Ihe properly, or my employees wilh ADDRE55 wages as their sole compenaotion,will do the work and � � � tha strutNre is nm intended or oHered(or sale(Section ����Tr � 70dd,8os�ness and Professions Code�. �� � - MO'/ING � TEL . � I,as owner of the property,am exdusively to�lrocting CONTRACTOR NO. with licensed convocrors to construct tha project(Sec- pDDRE55 � - - - � � - tion 7044,B�siness and Professions Codaj. CONSTRUCTION LEN�ING AGENCY� SET�BACK YARD HWY T�T'4pR�OpLINE VdIDTH ' ' I hereby affirm thm fhere is o construcrion lending ogency(or iRONT .q� � � $A the performance of Ihe work(or which this permit is issued . . P.l. (Sec.3097,Civ.C.j. SiDE ���� ' '� P.l. lender's Nama /'� if'�7 S�Q� � - P.0 Fee 5- Permit Fee. Q', tD1�'a a`f.x ' . .�5�a p 0� lendet's Addrees • 0�1,0 5—8 9 � I eertify thnt I have read this appllcmion and state that tha _ . is�vance Fee �DMA P/C N g obove informa�ion Is correcf.I ogree fo comply wilh oll Covnty Inveirigoiion iee '1 'q ordinances and Stote laws relating to bollding construction, Torol Fse � 'vo �phw ps.m.N - . R and her ze reprosenlalives of thfe Covnty fo enler � - - � up eT1 ve-ma tion'ed properl spec�f�ton.�pu�rp+o�ses. . � n �.�F��1C—/ fEE REV[RfF FOR FX►UNATORY IANGUAGL _��_ � Slgnatu�e of pp�cont Aq�nt . pota � � - � o -��a ' G� � 'o a ' . ;�� � ^�,1�, .p �J �� y - � � O 'n m O r h'fl ��rt, O '�' a cGi � v � i iD .. .p O O � r .e, ,D• � c� Lf + '� , O ,tt a ��•�n ^v 'i O Q � + `��' ` � � . . � �,�1 ,a �'� .rj ,"� . ;:� ', C ,+ ` �� � '" ' • y c , u+ o � i ,� , _ •� ' a.o a o . . �, '^ o. � � v C�' �' °��, o �o , , .. � �� 0 C p, n j -'�O � ^ Q •? �t �.�. , �1 ti Z � .e� (�S � ` :i7 n p' qo, � �✓ ': �� O ��� � � . . . . � �O >> �'�c' �� � 7 CL `"`' �, < i '� •1 � ::' + , ��. � � . � r�e'' q� ^�• 'Y� (?,'k � N "' i� • � N , m p ,• � ^ . o ' � � o h , U a r ' � , � � , ao c. ��� � 0 5 � D a . 2 ���3 "c��� ,� � ,p . � o.. .+ 7 N.^ � � �:7 .. ' , � . \ �i' . a;1. ' a •, -�`o ' r � p .. . � � '��, � . . 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