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y , ...,., . , ,.;,, -•. _ _._.__.._._ _ ._.._.__.___._..._�___.__._ .._._._ _. . ._ _. _. ._. . ._.._ WORKER$',COMPENSATION DECLARATION � - ���' �' . '. �' •�: . •.'.'•': � .• . - . . . ..., .....�._�,_.'... __ . . . I�hereby affirm tha�I have a ce�tifimta of consent to self APPLICATION FOR��BUILDING�- PERMIT- �������� � insure,or a cerlificate of Workers'Compenso�ion Insurance, or'a ceitified copy thereof(Sec:3800.Lob.C.)' . ,'.' . . ..-_...__._. . .. ._ . . - - ..' '-- -.. . . _ _.._ _.. .-.- _ - - . ' 61WETX79 •, , .. ,, COUNTY OF LOS ANGELES j BUILDING AND SAFETY -' ��YNo. �mpany HdPtfOY'd GPOl1D - --. _ . _-- _ Certified.copy is,hereby furnished: FOR APPLICANT TO FILL IN Bu��o�NG / ADORESS C D � �r(/ZPti.r� ��,Certified copy is4iled with the to My uil i- inip BUitDiNG /� '�fion de art t.... ,. ADDRESS . ' /�' . . ... , . . .... .. .. . � ' . . . ... . ... . . ... '_ '" "" ' Ddta — Applconf� � - CITY Diamond Bar ZIP � LOCALITY � � ., - ICAi OF'EXEMPTION ROM WORKERS � `�-'� " ' - .._. -..._.. . ........_ ... NO.OF BLDGS. - '-- �--''. taEAREST__..._ ...._.__ ..._ ___ _ .--_. _. ._.._.... CERTIF �' COMPENSATION INSURANCE-' �. SIZE OF LOT NOw ON LOT I � CRO55 ST., ( �.. . P'. ' 'P- ` _.. TRACT ._.. V BIOCK.__"'_ . . _ LOTNO-._-_,r.I._: ASSESSOR. .. , .., •. � .. .. ..... � This�seHion-need not ba com leted�rf ihe ermit n for one - - ----� - � hundred dollors(E100)or less.) : - � hwP BOOK ���� �� � FAGE PARCEI ' TEI. �5�,7nNE hWP ;. Icertifythot�inlheperformanceotthe,work'ro�wn��h��h�s - �-Bramalea-Limited�� ---�No��850-1001 T� p�p. . .���� _ � . . � �� permit is issued,1�sholl not employ any person in ony monner , ADDRES$-3�5�-.Al T'WdY.AV2.�-SU1 t2--N------� �� ' - SPECIAL}--�-�. --�-;�- � - - - - --- -6. r ' so aslo became s�6ject to fhe Workers Compensation Laws. � - V - CONDiTIONS , '��� _ .. .. ,. .. .. . _... ., . .-.. ' .�__.... . _ ._ -.. _ ....... . . _...'_ _ ;. . _._ uTr__._ osta_ esa. - ---z�P.-92626-.--- Date�� '��� � ' � 'Appl¢ant' �� qRCHITECi O " TEL � 'O l ICE 10 APPLICANi. If,�offer makinq this Cehificafe of DISTRICT GROUP TYVE fIRE PROCESSEDBY.. FNG�NEER NO. - CONST' Z E ~ pt on,`you khould become subjeN fo the'Worke�s' --'-' ,. 'U Compensation provnions of�he labor Code,you muse For�h- qDDRE55 3990 Westerl Pl. �Ul t2 �7� -� ��-- W - �-- -._. . _.. . wifh comply with such provisions or.ihis pe�mil shall be'---- �. �� � 'ean deemed revoked.� • �.��'�,.;'•. � •- TE�• STnnSTiCnL M59FlCAnON A . CONDO. � ���'�'�'� �'�- -��•� `�-`- CONTRACTOR Bramal ea Cal i f No. 850-1001' �L� � �Z LICENSED CONTRACtORS�ECIARATION •��,-.•�.� ---� �-��--�-��-�-�- ��- �;--�.��--����-� � � - --�-��; ��[�ASS NO.�DwelL UNiTS_L UC: I hereby affirm that�om licensed�nde�provisions of Chapter 9 no�RE55 3151 Ai rwa Ave�.�N No.409610 (tommericin wi�h$eclion 7000 of Division 3 of the Business ond _,_. � ��R�P ' : ' �� � � ''� . Professions Code,�ond my license is In fu�l force and effect. Gitt COStd�M25d CA� c�.ss B � --���BK--�-� . --- - ; -- -- VAUDAT�ON-- -" . �' -� � � - ' - 50,FT. NO.OF .NO,.OF;, CHECK �. � _ ticense Number 4096�O Lia Clai's � B�'�� SRE� STORIES --- FAMIlIES � ONE � �: - ' i,-. ,. , ,...... �..t ,• ---- oeseei N c woRK-- PLAN-25=/- ---... New--R] --vnwnnoN- -- __ ; - �0 9 2 8 A ' co�vo�ro� Bramalea Calif �,e � �� .. . ..... ..: .. � , ADD � s ��.._ _u.�•..0.•2.� . �1 om exempt under Sec: --� -- -- � -F Rl� - d ---- -- � ----� ALTER. ,.. . . . _.... , . . . .."_."" .. . . - __:___. _J.�381..10 B BP.C.for this reoson _. ' REPqiR_Q "'f'�' `�S'-� : � ... _ . .. .. . - . _ Datei `-_� , , USEOF . / _' ... �EMOL 4 J R. �;. ' � .....__. E%�STINGBLDG. � � _. _ .. _.�_° . ��.� D' . � ���S'�nnfure '• � ''- -' ... APP�ICANT TEL. . FINA� /J ' � lowr for ha�rfallowin�m UILDE CIARATION PRINT Np. - ..DATE ��!��I�7--�•'- � ��'2 O-�b � � . O�NER- � _ _ ...- -� ----��- ----.... . . . . - y exemplfromtheContractor'sLicense qDDRESS 3151 Airwa Ave. N�Costa Mesa � �r,n� �.:��/ - g�eason(Section 7031.5,8usiness and -/������ ����' ' �� ' ..PrbfessionsCode):_.__ . ._....... ... _ . ___ _. . __.. PgE eNi ...BY /d-R�`�.....-_ .. � . � � -� BNLDi�IG ; . . . . - ' � I, as owner af ihe properry, or my emplayees with nDDrtESS ' --- --- _-_ _:.�G y'L Y N_. � _ . _.-' - _. _._ _. .� woges ei�heir sole compensa�ion,will dOlhe work and � - . , � the strvcture is not tntended or oifered for sale(SeNion ����TM ' � - � � .-- - 7044:Buslness and Professlans Coda).- ---- ---- --- --... MOVwG--.. " '--' -- � ---- �- - TEt.- . __ '. .. ._. ._ ... -' - ��o s • a � . y�i I,os owner of the property,am exclusively contracfing CONTRACfoR NO. � , ' `: _., -'�. V �� , � NA - ------ --- --. _ . _._ ._ .... -_.... ...__.._ __.. .-'- - ---..—._. . : . _. b.��.4 n wlihiicensed conrracton to consirucf rhe pro�ect�(Sec- qDDREsS ' - - -_tion 7044,Business and Professions Code). ' �� . • ,. ,�! ' _REQUIRED_. . i0iAL5ETBACKFR ... 1 .� __..._...'""___.. _'_''.•_i..�-_._-'.-'_: �..°.��J�.00�--' CONSTRUCTION�ENDING�AGENCY� �� � ��� ���� SET BACK YARD' 'HWY PROP.LINE �'dIDTH I hereby offirm thot thera Is a mnstruction lending agency for fRONT � - �'. . i ` � - -.---- 0_5.20� f36` - 1he performanca of fhe work�for which this-permit is issued ..._ . --P.L-�---- ----- ---- ---'.....-.------..... .----., .- .-.. ..__..._ ___.._.. _�_�__ . _" ($e[.3097,Civ.C.J. SIDE . � - ' � _ . _ .-Toronto Canadian'Bank__ _ P.� _._.. . ---. ... _ . ... .. ---- • . Lender's Nama �' ___l44 Sansome_St.�.SllltE_JOO p,G.FeeE �`�j IDMA Ref.p • - ��� � Perml�fee.._._. . ) _ ._ .__ ._. .. Lender's Addiess • ' �7 .� �' --I certify thotl hove read fhis application ond s�ote thot the -._....._. . .-"--.--._._/�^G'71_.... IssuanreFee--..�.�0"��...� �DMA PiCN--'- ------ '-_ .. '� �- -..: � obove in(o�mation is torrect.I pgree to comply with all Coonfy Inves�igoi�on Fea j� ; ' � _ � � ._ordinances and 51a1e laws relating to building conslrucfion. . _._ _'..___.._"_."'__.__ .- Torol Fee- �,7-�-'JD .� �LDMA Perm.N -.... ... ....-.- ' - " ,..........-..�:.��,� ..' ' and hereby authoriza rep sema�ives of this Coumy ta enter ' � � , � upon the abave- eni� n d pro e or inspection pu oses. ��--�'- � - - ._ _._ . .'_ _ . . _ _. . ... ... . _ .._ .. ._. __.. . . _ .._ . . . _ _.__. ' '_ ----- --- - �' - SEE REVERSE FOR E%PLANATORY LANGUAGE � - . .__.__ ign v of Appl c �or Agenf .... __. -- Date._. _""_.'_ . . ." "_' "' _"" ' ' "' � -'.._ . .....' 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