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. , . . , , .,, -- - . --- ... �.. _ __..__._..___ ._ VJORKERS'COMPENSATION DECLAHATION ':". . ��• i . ..�_....�...�. .�...'�M - - - ���� �� � "�---"-' � "._ ..-" � . : ..,_.. � . '_-.'- -.- . . . . ''. . . � ..BV L . � _. . ( ( , 1-herekiy aifirm rhat I have a certfimte.of�o�5e�„o Se�f � qpp�ICATION F�� R-: I �DING PERMIT--�� ���� . maure.or o-certificate of Workers'Compensa�ion Insurance, or d ceriified copy�hereof(Sec.3800,lob.'C.) ` " " ''- - -- - � . . - -_ -- ----- COUNTY OF LOS ANGELES , BUILDING AND SAFETY ••� Pou�,,No.61WETX799?�om�„YHartford Group �'•' --. ,-- - --__ � - - � Certified copy iz hereby furnished. . ;.:t, FOR APPLICANT TO FILL IN BUIIDING ; ' � .. --.. . 4 A�DRESS � � Certified-copy is fited wi�h the couniy building Inspec- euaoiN� "�libn deporfinenf.��'' ' �� ' ' ' ADDRESS 1049 SO v' W � ,[j 'i i oo�e• !ZS—�.nPPi;�a,,, �. _ _ arr Diamond Bar z�r �ocnurr ' '.� �. CERTIFICATE OF EXFMPTION FROM WORKERS'���� -"-'�' --�-----. . .._...-_.... .-- ---NO.OF BtDGS:......-. _. . ...- NeaaeST� '._":.—'---._.'-'.._._ ___� . . . ' �- ' ��� �-�COMPENSATION INSURANCE'� � � SiZE OP LOT NOw ON LOT ' CROSS 5T.. � --......_-_.............. hundred dollars(S �ed if Iha permit is for one - --- --�---- n --���--- � ^ ASSESSOR ._ - - - � (This section�need nol be comple 7RACi YZS6 �-• BLOCK LOT NO. 11��- - � ��� � M4P BOOK . `� .`, PAGE '.:�:.�.�. ermit is issued,I shall not em lo' I tertif thal in Ihe�erforlmonce TFt. . ___�`E �P PA p � 1 P Yanypersan� .., .. .,�. . ..- OWNER BPdfll 1 a-Lim' d-..---- No � � � - /3 _3R� Y, p of�he work.fo`r whic this - � 1� Np t . � inanymonner _... . . �.. . - . __. SPECIa6,_.._..._.- - ., ,/__--_-_ ,�_-_- - } nooRess---3151-Airwa -Ave.-Su�te-N °� so as to betome subject to the Workers'Compeniation Laws. �"�-- J CONDITIONS �� ,. ... . , .. �., �. . �.� . • � , ._ '�. -- � c�n__Costa..Mesa CA... ._-z�r_.92626_ _ ------- __.... .._ . . u ... ._ . __._ , - -- - Dare :.. ..�. ."APPlimnt�' . .,. .� - '� � �ICE TO APPLICANT: If,'oker makmg Ihis�Certificofe of ARCHRECT OR " � . TEL . .DISTRICT .. GROUP TYPE ,FIRE _ PROCESSED BY.�. � �nphon,�yov should become svb�eU'lo'the Workers' �-�� � ENGMEER Aram Bassenian r,o.752-1864 . mNST E � G I Compensation provisions of the Lobor Code,�you m�s�forih• qDDRE55 "" with�comply with�•such provisions or��ihis.permit sholl be" - -- 3 • I -� - �3 - � '��� y . deemedrevaked.. - ..;.. � , .�, . .,, •�. „ ,� TE�• STATISTICAlQHS51FICATION� � APT. CONDO.��.� coNTRnc,oe Bramal ea Cal i f. No850-1001 - . �/ _ z IICENSED CONTRACTORS DECL4RATION .•, ���- ��� --�� . _.____. ....._._.____.i�� ...__. __._ - cv,55 NO. � ��-ow¢ii.urmis._LL.� � � �' I hereby affirm thol I am litensed vnder provisions of Chapter 9 ADDRE55 3151 Ai rwa AV2. N Ho.409610 (tommencing wi�h Section 7000)oF Division 3 of the Business and _.,_. _. SEWER MAP � . . � - . . ._ _ .-___ . -LtC.-- . .. . . . Professions Code,and my license is in full forte ond effetl. Gtri Costa Mesa, CA. «q55 B �-----�------ �--:�---- '- ��---��----�- -�.. - . .. .. . . .. � . . � gg. p� DATION VALI . . . �, .. . . . ,-. , ' , . ,____ SO.FT. ' NO.OF NO.Oi CHECK � � . . � - • . . . . ._,_ License Number'-'� ��"C'c.Class �� � �� $IZE STORIES FAMILIES ONE '� ;�, � � _ ✓ A'� .I�A ---SALUA��_�I��--;� ;_ �,. ,�.0.... . � Bramalea6Calif. 7B�/�� _ oesca�o,�oN F�oRK :/-- - _--- N�-- - —� 81.6A.: � �-: , � .-7 . . I.Ai Conlracfor Dafa-���'�-'� ADD Q ll7J �t• • e�•2'�. �I am exemp�under See. .._._.. • . . .. � __ __. . ."-'-'. - _.- ._. ._ . ... .... ,. . ALTER � '�� - �. : � I •o4�6� B.BP.C.for this reason 2W Construction REPAIR ❑ -S - -` - .- -- _.:_ .._ __ _.__ .., ___ �__ ...._... .__ _. ..... ........._ � • USEOF � � �, Dafei'--'�-- � EXISTING BtDG. DEMOI Q ' • " ��l��J 2 u • . ...1_.__.._._.._ _..".' .�.: _ _.. ____ '-'---Sinnarure " - - --� aPPIICANT tEL FINAL � �+ ' PRINT N ' 1 O O.� �l`S 6 0�1 NER-BUILUER DE LARATION � ' ' --_pATE-� ��?_�'� - __._ __ _...._ � -..'--. . _ --------- ._. . _ �-I hereby aifirm�hat 1 am eaempt trom rhe Contractor's License ADDRESS 3151 Ai rwa AV2. N. Costa Mesa� ' Law for the following•reoson(Section 7031.5,Business and flNAL"�� � '�'^/`J' '�"� � � `Professions Coda);....__..._. .--- --.._. . _ ._. ... -. _ ve N . _�By �-�l�-Lj'`- - � �- -_-� -- "� BWLDING . .. . .- �� �..- - I, os owner af the properry, or my employees_wirh ADDRESS . . _. . ..� u�•agas as their sole compensoiion,wiii Jo Iha wo�k ond .__ - - � J --- the structura is not Intended or of(ered for sala(Setlion _ ��`�� � \ � . - .. ...-7044:Buslness and Professlons Code�.� - --- � MOVING� .. . _..�----�-----..---��7Et. ....._. -._-... - - . ..... .. .�. • . . . I,os owner of the p�operty,am exclusively mntracling COM2nCTOR MO. ' ' '�� �,__._'1�; ci } t3 1 /R '❑. with Iicensed[oMrottors to conslNct the pro�eU($e[- . ... ... .-_.. . ._.____._-.__ _ _...."___. ...__'___.. __._ _... ..._"' �'.�' .. - - . ".._._Ic:�5 8 a Q� lion 70Ed,B�siness ond Professions Code). ADORE55 � , �- --- �- REOUIRED... TOIAL SETBACK XI ---"-CONSTRUCTION LENDING'AGENCY "�-" " �--'- 5Et enCK YARD -HWY' '' pROP.LINE WIDiH -� - �`�� ""' '--- ��O O=i-� I hareby affirm Ihat�here is a tonstr�Uion lending agency(or FROrvI . � . � � . n p � -.�he performence of the-work for which�his permii is issued -'--•� -PL. -.._.. .. .---- -- --� -'-.-..-.--- �-' -�-- '' - -. . _... _�.�__:.. '_ .". � . _�.C:.� 9:"a��]_.._: ($ec.3097.Civ.C.)• SIDE ,.. . . ... , _.__. . ._' "'_" P.l. ._... ... ... "'. ... ..... ... ._. _�' ......'_'_. ._. _ .bF.,. .. .�. , . � �end�,•,Nome Toronto Domi ni on Bank _..-__.. . .._1... ..,�: __ a ns ome . u� e P.C:Fee 3 :"m�" Permit Fea "-��/'J�/ ._ lDMA Rel.# ' . .__ . .. _ . . �_. . .__ .. ._"'_ lender'sAddressg.�r �ransYsco ��a4�04 � y���� "�,1 �-5� . . ._-,� -_I certify that I have read ihis application aed stafe ihdt 1he ___. . c/'�+""�',�Y_._..J�.�'(l__ Iseuance vee�'-�.��-.J�v_....,. IDMA P�G#--.-_ . _ ... ,.-� .._._. ' �._.r.:' �:--, obove information is correct.I agree to comply with all County imesrqmion Fee "���., ' __ordinantesandSlme_lawsrelalinglobuliding.constrotfion, _ ..__.__._. � To+alFee--�up'�Va��- � LDMAverm.N-� ' �� �� ,,. ._ .._. ._ . ... _... ... ._. __'_ _.__. � ... .._..'-:_� �.. and hereby ou�horize representatives oT this County to enter vpon the o6ove•mentioned pro ty or inspectian purposes. ��,,,.y � . . __. __... ._ _ . ...- - -- ---- ---._.. ... ..--- e' _"�f�.. � ...._ - .__-- �--� . . ( �j��6 SEE REVERSf fOR EXPLANATORY UNCUAGE � � -- - � . ' _..... S�gnarura of Appliconl or Agenl ._. .'..___'.Dare._' ' .'___ . ._' __. _ _"_ "_"'_"'__ ' _. .__ .._. _ --__._ . ' . '.__ _ _._ , ...__.._ ._. . 'Q� � :.._ - _ p ;o- . � '� _�. o" p '; ,` e .�/"i+m� �p� p_ p ? ��(1 y ♦�� G ¢•` • �-9 � O�p. 7 � p �•�^ •d � �O O O f0 n�N m.� ip 0 � � 'O, . �p . Q a ^ a �o o: -3 ° ,,o `' �, .� ,o r � � : �'� co "•� 1 � . Y -n i!N� �O 7 �m� O'�o _ '3 m \�, -.''"i i - .n + C � O � O� O �.. 7 � ,. . 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