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, ,.. ___ _:---._...__- ___.__.�..- -�------..--....---- . _,.__... --,.... .. .Y WORKERS'�COMPENSATION DECLARAiION ;.;„ . .,y. „ . .,;- . -_._... _..__...' -" .'.'. r :.. � , .. .. � . � . .._...._ _._....__ ' . . I . . . ' � msurtboraaiCe r'fhot,l ho e o�cer�ificare of toniero�o�self APPLI�ATION��FOR�BUILDING� PERMIT�- � � , ate of Workeri Compensation Insurance, " .---._ .. . .. .. _.... ... ... _ . ...., or a cerfified mpy Ihereof(Sec.3800,lob.C.) "' , �� ._ . .__._ ._. _ _ . . • •^ - • -�• • �� • • COUNTY OF LOS ANGELES ' BUILDING AND SAPETY ,., PalicyNo.61WFTX�(3om��yliartford Groiio -• - ���-�-�- � �- --- -- - - - � Certified copy is hereby fvrnished. ' . FOR APPLICANT TO FILL IN BUIIDING � ADDRE55 !os �,�.;.- . � Cerlified�topy is filed wiih tFe toonty 6u Id ng inspec- -�"��- BWIDiNG �'-tion deportmenf.� � --� • � � ADDRESS 1057 South Lon V1eW �� � ' ' , .�. , .', :. '.,.�� -' .� .'__. . ._______ . .__. __. __ ...__ ._-'-___...___.. ._ Date���Applicam Citt Diamond Bar z�P �pCpiiiy � ' � .�. '-..CERTIFICATE OF EXEMPTION FROM WORKERS•;.`. . ._._._._..- ..------'-- -- NO:OF BLDGS.---_--..__._-. _. NEAREST __... ..'--'"-----''.. �'--....... .-"-"'_....._._. ...._...� � �� � �� ��COMPENSATION INSURANCE�-�-�'�'"'�� �'� S2E OF t0T NOW ON LOT CROSS ST._ � (Thls section need nor be completed if the permit is for�.ona -�•,�-- �� �-�� ASSFSSOR._., , :--�-- -- �---�-; �:��-,-� � ... ._. .. . .._............ . , hondred dollars(5100)or less.) � . . , TRAa-4256 V BLOCK LOT NO. 9 . �� MAP 800K - GAGE; PARCEL . � ,• .. � ' . TEL. � �., , _ _ _ owr�a6 m 1 - �m� d -�- No. _ ..: u�r,z�r� rn.av ///- '�7 1 tertify thot in the performonce of Ihe work for which.this ' � �b. "� �r 37 �--'�� �} I permil is issued,I shall not employ any pe�son in any manner � • • � - � -- SPECIAL• - -- ��--�- � -�--- � � �� O. - �"� � AODRE5531rJ1�-AlY'Wd Ave:- Suite-N - ---- - � � CONDITION$ ' � .. �v so-as,to 6ecome subject to the Workers Compensahon Laws. . �� '� oare ' " naal��aoi.: ... ,. - . . arr._COSta_Mesd CA.._._..._z�v.92626.__ __ __ ..__. . ._ _.. : - - -- -. .:, m � ^�ICE TO APPLICANT: If aRer'mdkmg-this Certificale of �4RCNITECTOr�r m B 1�1 N . � DISTRICT,_ _GROUP TYPE..�__ FIRE PROCESSEDBY_.. _� I Jlnp�ion;'�you should become sub�ect to"the Workeri ' � � ENGMEER � .- � � ZONE ' Compensation provisions of�he lobor Code,-�yo��mus�for�h- !7 �T � ._W ADDRESS 3990 Westerl Place, Suite 170 � ._ � __.�-3_ . U...':--... ith.comply ith'soth pravisions or this permit shall be ---- TE� � � � � �� �v4'i . deemed�evoked.. _.�. -' .� ,'• ..� •� � _..,..; � - 57ATISTICAL CL4SSIFICATION ; � AP7. CONDO.�--� ��Z , coNTRncro�ramalea Cdlif. No. 850-1001� - -- — . . ._ _ _ _ LICENSEDCONTRACTORSDECLARATION � t -- - ._._. .--.. - . ----_._.._..._. . . _... . -t�C.._._.._. ... . Qp5gN0. ' ��vVFIL�.UNITS � - � 1 hereby aifirm Ihat I am litenaed vnder provisions of Chapter 9 A�DRESS 3151 A�rwa AV2. N r,o. 409610 ( . ,:.:.g Y7000)ofDivision3oftheBusinessond .._. _...._SEweRnnaP � � �. � - commencin with Section - - -.._ _. _ . ..__ l�C .._... .. --- . . Profess�ons Code,ond m Iicense h in full force�ond�eHect. qtt Costa Mesa CA.� nnss B � ----�- --� - , . . � . .. � . ' BK. PG.--'� _-. -.._ . . VALIDATION"- � SQ.R. NO OF NO.OF CHECK..: ' . ..., .... . .. ��. . . LicenseNum6er 409fi10 � � ' i,�Closs R " SIZE 42 STORIES 2 � FAMILIES 1 �� ONE � . , . ' . w� . _ v i - - - -�Q�12A A UAT ON, , CoMratfor.. .•. . � Data '-� " DESCRIPTION OF oeK-----25B.'f- _..- .- A D-..� = l�S"'-'�%�-i - � . Sin le--Fam�l -Residence � - � � �-41 ❑1 am ezempt under Sec. � � ...�� ._. . __.. . -.� -. .. � . . ARER ,i�_ _ •J F�5 L�I..Q , . . . . , ,.• .r:. � � �, . .B.BP.C.for�thisreason ._._.. _ N2W Construction REPAIR. Q ..._;..._..__... . _. _.__ . " . '_ . ' _ . .. . ._ . _ _ . _.._ _ __ oo�e:___ - ': use oc � �ernoi ❑ ; ` a A�II 1.1 �� : EXISTING BLDG. ... ...�- ___._... ... . _ -_'__''"__.._.. _ , ...._... . -�-Signature " � APPIiCANT iet. FINAI ' � ; 0�1 9-8 6 OW ER•BUILDERDECIARATIDN PRIM Bruce L. Abbe No.850-1001 ....oATE�_�1�(�n��i• ---� --�- ' ' - —- - - _ � 7..._.. - -----.. ....----- -•- -�Ihe.ebyaifirmtha�tameaemplfromtheControc�or'sLicensa ADDRE5531�j1 A�I'WB Ave. N. Costa Mesa FINAL�� '� Low for the following reoson(Section 7031.5,Business and ' ' "��' '"' �- ...Prafessions Code): . . -.__. . .,..._..._ .___. _._. .__-.. veE Ni -,By. ...M(��'.__� . '-'� � - euimu� ...�•., �.\� /�_I, as owner o(the property, or my employees with _ nDDRE55 , , _,__ _ . _ _ � • ! � _ wages os the�r sole tompensation,�wili do the work and � � ._U L I,J�H _ ." _ � ihe sfruc�ure is nof infended or offered for sale(Setlion ����TM � ��� � � .. ._...'704A,Business ond Professlons Code�..... ..----� �- --'--��- MONNG -'---�-------- -"��-------�--TEL:-.. -...--�--.. ' ' .....- ' � �• r t.• r� . `� . ,i I.osowneraftheproperty.amexdusivelycontmcfing ..- -..--'_---- ------J- --.--_----...-.-----. . .._._ , �� 'L'ti'.� .� ' ..� -��❑'� with I([ensed conlroctors to constroct Ihe pro�ecf(Sec---�- � ADDRE S�OR NO. . � __ _�` \' __ ; ��R b�5�,�0 �' � . tion 7044,Bosiness and Professione CodeJ. � - � _ ;: ._.._._. .REQUIRED.. . �OTAL SETBACK FROM - XI --� ' _. .. -"'� CONSTRUCfION LENDING-AGENCY ��''�"' SET BACK YAR�' 'HWY ' PROP.LINE WI�TH -'"-'�--�"- ��-��- - �"". .�--..�_. . . .....-�.a�,.�a a L'I 1 he�eby affirm that there is a constrottion lending agenty for FRONi �'� ' � � �'� � � � '�- - . � , -the perlormante ot tha work for which�fhis permit is issued ._-. . --7.�...--- ----- ----- —'---------� ---.: —..--- -----�--- -'---'�-�---'---..-. . ..�-�.�-9`G O-, � (Sec.3097,Civ.C.). SIDE . ' - � � --Toronto Dominion Bank __ _ v.�. -. _.._. . _ .. __ .. ' - ----- -- , .:' ` �... - .. .. :... - - - - -- _.. lender's Name � , _ 144.Sansome St...Suite_7o0 __ G �� _ 1D"^"Qe'�" � �' � - --�-'.. .. P.C.Fee 5.. .:- ��'-- Permit Fee.- ' � ' _.... ,._..._ .. _.._ lender's Address��� y 1 � �� � �� • � � Oc.� �rN IT � ' ,. , --i certif thaf I have reod this a limtion.and stata thm.the "��"�' �.� Y� PP .' '- _ �/�' �- ��-�--� lesuence Fee.....-'Nr�_'.• LDAM P/C�t-.'__."__'_ . ..,'.�:; __. _ '.__. _..._..� ..._... _.._.___ .. above informalion is correct.I agree to comply wiih all County invesi�qoron cee ' _.ordinonces ond Stote.laws.relating to building consfrucrion, _... _ ............._.,-._----.--_-. i ' : ..�•i ��--� �:.-. �To�olFee--�r��.-�--.• -LDMAPerm:N-______.. . .__... .___;........ _.:__� ...- i and hereby outhorize represemmives of�his County to enter __,,.,_ ' upon�he a6ove•men�ioned properly f r Inspectlon purposes. y� p. . . � ' � � .. _ .. _ .- Ot:.l R-1 .�c� - ^ .. _ . . ...._.�. .. ...---' ,/ �7 [`� -' --- '- -- � �I - - --y T"__�- --- -- '_, �'7 .SEE REVERSE FOR EXPLANATORY LANGUAGE "'� �'"S;9na��re of Applimnf or�Agen�.. . - � ` �. . _ ..-• . � _ i , ,. . "" �ate" ' ._""_ .._.. __ '___ '._ . ._..'_""'__ . ._"_'- ._'."'__ _.'__."_._ ___ '. '.� . 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