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0822A 0823A
, .. . . .. . __.._. . ._ , w_. _.__.....__..-- ---..__�__ __ ._._.- -- -.. _.._...__...._----- ---.,- WORKERS'COMPENSATION DEC[ARATION "�:'' -- -..^•.' - -,�.'���. � -'�.: �* �,. . � � � ._. ._....._.._ . . , .._. ... . . . . . . � l . I.hereby a«„m,�o,I have a cerfifimte oi consent,to self APPLICATION� FOR� BUILDING� P�ERMIT—�— � . msure,or o certifico�e of Workers'Compensation Insuronce, _ '� ' oi a�cerlilied copy thereof(Set.3800:Lab.C.) •:' . -. _...:... ... ._._. ... .. .. .... . .. ..... . ,__„ „ _ COUNTY OF LOS ANGELES � BUILDING AND SAFETY '� � rortyNo.61WETX799�om��YHartford`Groun '��` `��° _ ---- � - � .Certified copy'is hereby furnished. � .... , . ,� FOR APPUCANT TO FILL•IN BUIIDING � ADDRESS JO ' , Cerfified�copy is Tiled wilhYhe touMy building Inipec- ��-�� BUILDING �/ �, /�7• , �'�'ti0r1 departmeM.'�''�� - � ' ' � ' AD�RE55 ' /..� • . r '... ' . �.,�� -' �- ... .. ..._. ._-.__._. .._ . . . _. . . ____ . , � Daie � �Z)' Applicant CITV Diamond Bar ziP �p�,uTM � CERTIFICATE OF EXEMPTION FROM WORKERS' �'�� �- - "'--�- `-�--'- �'-----��-' -"NO.-OF BIDGS. ��- ----- i NFAREST...- . .... __ .__.._. ._ .�.__._ , ���� COMPENSATION INSURANCE� S¢E OF LOT NOw ON lOT ✓, CROSS ST. . i i . ., ,.., �... . (ihls declion need noe be completed.if ihe permil�is for one -- � -�- -� ASSESSOR.. ,� •� �'�- "- .'�.� ' .' . . ___._.'. _._..-._ . _. ' hundred dollars(5100)or less.) ,.- . , TRAET -4Z5F) �%BLOCK LOT NO. 14 Y Mqp gOdC � PAGE PARCEL . . I�certif ihaf in Ihe� erlormante of th ' • ._.. TEL. ' • � ---- owNe�Bramalea L�mited- - No850-1001- u oNe rnnP r �f y p e work for which ihis , ��J/ �. . jf''3 ' �� 37 � '} permit is iswed,I shotl not emptoy ony person in ony monner • • ' ��``�.� S7eCinl ��-��---�� ��- --• - --- ��� �-�- �-'-- ��. I so os to become subjed�o fha Wolkers'Compensafion laws. --�� ADDRE55�31 1'� V .�-- 1 t � ��-�---' c�/�T" CONDITIONS ' . . ��. � ��� :� . :,: . . . , .. . . . � �� . . , . . . .. . ._... . _......_ . .... ._. . _..__ _.. u .. � �� .. ... ,. ___..- GN . ._..... .ZIP_ __ .�... � DISTRICT_. GROUP�. .., Date�" '� � .•,�q�Pplicant�� '. . .. . �pC "�ICE�TO APPUCANT: If, after makmg thi§Certificote of ARCNRECT ort TEL. __ _ �O I ENGINEER Aram Bassenian NO:7��JZ�iBF� ' TY�- FiRE . PROCESSEDBY._ �nption;`you should become sobject ro`�fhe Workers' �---- , Q COCI6P- �OtdE- _ �;rj �ompensation provisions-of the Labor Code;you must forlh- pDDueSS Westerl Pl aee Slll t0 170 . _.. !l7.._ /l 3. . wilh tomply,wilh suth provisions or Ihis permil thall be --�- . �H deemed revoked.. �,•,. �� � �� �. -��� - � � TE�• S7ATISTICAI QASSiFICATION AVT. CONDO. . ';Z � � � �� �, •- GONTRACTOR Bramal ea C.d�1 f. NO. - y/' .. . '.._... . . ._. . _ _._._ ... ..._ LICENSEDCONTRACT025DECLARATION� ��. J --� -- ------- ��-��- �-� --� �----� - - --�--- IXASSNO. �� DWE�LUNitS� 1 hereby offirm thot I om licensed under provisions of Chopler 9 ADORE55 3151 Ai rwa AV2. N No.404610 (tommencing with Section 7000�of�ivision 3 of�he Business and ��,. ��R�'P � � '��-'�-� �� � __ ... . __.._ -____. _. ._ ' _._._ .___._._ I . _ Professions Code,and my license is m full force and;effect. C�TY CWSS � -�-----"� - � � •--- '�� � �- --VALIDATION�- � �' - .. . ... . .. � �� 5�.F .NO:O NO.OF __ CHEIX � BK. PG. I ; . License Number 40A61�' ' u�.eioi:B � _ _." s�ze� 84 ' sroaies' 2 _ rnnnaies 1_" ' oNe - , � . . . .. .- p V l T�O � co�r:ouo� BY'dtnal ea Cal i f Date ,' -- DESCRi ION OF�r,o ic�- _ _. .��. _. -- --� -"SA UA ON 7� -- ` � °0 8 2 2 A NEW � .. .. . ... ADD � . ❑�om exemp�under Sec �- -- - 5111 �2 Fdflll� R2S1 dEt1C@- - A��R � � , " u�"� 2�� . ._ . . New Construction � ---s---� -------� - - _- ;. _. ___ . 8.8P.C.(or Ihie rea5on REPAIR.. ; ; ; I ��2 Q 4 1 � - _._. . .. .... . . . . . -... USE OF � °ie' EXISTING BLDG. DEMOI ❑ ' �( p���/,, � AFPLICANT TEL. �, � �J x Q 4�� � , -' -Signofure t{27�V�✓CX/ ��LLCTI'f�u'Y FINAL � . ��r+T ruce L. A6be No.850-1001 O ER-l�l BUILDER OECLARATION __. ._ _. ._ . _.._ . ..__ ._ . .. DATE-''�y%O ✓�". - -I here6y affirm Ihat I am exempt from Ihe Conlratlor's �cense � � �Q G�� &,� ' Low for the tallowing reoson'(Section 7031.5,8usiness and no�aESS d FINAL"�" ' � �- '-' '� � w.. .,Pro(essions Code): . _-_ __ ..' _..... ... �..... .. -'.' PReSeNi .'-By. ._ ..----� - -. . ... - . .. BU�IDING � ' '� 1, os awner of the properry, or my employees with aooRE55 :♦ � ����whges 6s their sole corimpensalion,will do Ihe work ond -�-- � � � ����' I , _ the sfructure is not Intended or offered for sale(SeUion ��`��TY � �b 8 ' . . - �7044,-Business and Professlons Code). .. . �..-. _..._.. MOViNG' '..._..--��--- ...__ ..... TEI. ''._. ." ' , ' . '. ... . ��-�� •���? 1 `. ❑ CON7RACTOR NO. " � , _ �� � 3A ; I,os owner o(ihe prope�fy,am exclusively contractfng - • , � wHh Ilcensed�controdors to consiruct tha pro�ect-(Seo-'- ' - ADORE55. -.._.-. � .� �'� ' � - �'. . -_. . �-'- ...-... --�� " ` \ ; ' --�-� -i' ��t-e-fj�9.Q Q -, �ion 7044,Business and Professions Code). - , -� � . �.�'� __._. '_ _. .REOWRED_ .YARD_ HW1• __i0iAL5EiBAIXFR M.__ %I . ._ ._._.. _. _' __��'.._ _ �.'._.__.� �[�-�J.00' -- CONSTRUCTION LENDING AGENCY ��""��- '-""- SET enCK PROP.IINE WiOiH � ''""'� �'`. �ihe pe formance of the work(orswhiclh th inpermt is issued �-�-- ��P.L.T------ -- ---. .-- �-"-�-. . .-.--- �----� ---'-._ .... - - .. .- �'--'''._� .. . _��-��(���8 6. � Y 9 9 Y FRONT __ ___.__ _. (See.3097,Civ.C.). SIDE . . � � � "� - Toronto Dominion Bank -- - - P.` _... ... __ . .. _. _ ..._. . - -- - - .__ __. _... Lender's Name t- � � -� � � ..14 ansome_ . ui e .. p,[,-FeeE ���ZD• I--- PermifFee�-V� rs��--. ���ReLN _ , � � - � �� . '. . ._ " �.. .._ . lender's Add�ess ' CA_ 9/1�O4 ' � �' San Frans�sco, "� , . __I certify�hat I hove read this application ond state.thaf tha /}wJ u ,V!/ LDMA P/C N '- � � ' . .. � . . . _.. Isauonce Fee..-_�d.q1�..�--' ....._ . _ ... _ . _ o6ove informarion is mrrect.1 a9ree�o tomply with all County I estigation fea ,(� p /� �'� .� .ordMonces.and Slate Iaws relafing.fo 6uilding consirottion, ._. Toiol Fee--v !�^��-- � ' IDMA-Perm.M- - � �� � , -_ __.. . _ '___ . ____._ . ___ __'.__. _-_._.. -. and hereby authorize representotives of thfs Coonty to enter ._ � upan the above-me ioned ro e�ty for inspection purposes. ' ; _;. � � _ r i_?� ' _ _ ..- --- .__. ---.....�'11wlA- 3S'. _ �ZZ�� _. _ _ _ . . � SEE REVERSE FOR EXPLANATORY LANGUAGE , � _. , �� . ... Sigrwture of pplicon�or Agen ....._""_' ....�re"'. __. ._.... . ...... . .. .... . ..__.. ... __'�_'____"_. . .. ... . _"_' ._.. . _ �_. .:'- . . __._� ..._"'. . � iri Z o: .f. 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