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.,, , . , . . ., __-�_.____-- - ----_.._____.__. . .---- ,._ .., . .__... . _ ._....__._...-- -._ __ _. _.._.._. G WORKERS'COMPENSATION OECLARATION . ---.`;f.;�•"7'-,.t ' ' ���::� � 6 .� ... .._....._ . . .., . . , . . .. --'--'--.. _ .. . _ . . . � : ,I hereby ofivm.that I have.a certi6cale of,tonsent fo�self APPLICATI4N� FOR�.BUILDING� PERMIT . insure;or a ce�titicate oi Workers'Compensation Insurance, . .._ .___-- .. . . . _ . _ ._ .... . . . ' or a certiFied copy Ihe"reof(Sec:3800 lob C.)' - "-' . COUNTY OF LOS ANGELES � BUILDING AND SAFETY ��� � � - ' voi��,.No.61WETX799dom��YHartford Groun -.- - ,- �� Cerhfied.copy is here6y(u�nished . FOR APPUCANT TO FIIL IN eunoiN� , ADDRESS U G`tR�tY ��,�Certified�copyisfiled�with�tHe'covntyb�ildinginspec- �-�-�� BUaDING ' /� 'IiondeparlmeM: ��� ��'� � '�� �''� �-` ADDRESS 1061 South Lon V1@W . /•�� , , �J -- _ . . oa,� � q i;ro„���' ���,J'��- '� citv Di amond Bar zir iocnurr i . 'CERTI�EXEMPTION FROM WORKERS���,�(/ � -..._"_.. ..-- '-- ���.OF BLDGS.� --- —�--: ' NFARESi � � � �� ---- -'..--'--�...r_ . . ...-._-- "-.' � ' � COMPENSATION WSURANCE' SIZE OF tOT NOw ON lOi CROSS ST.� - .. . ..,. _ . . . ' for'one - . �! ._�...' ASSESSOR., . ,. . ......_. . _ _. ...,-, . ... .. -_, ; . . __.... . . .. ... _.__ ___ .'. ..._.. ��• �� (Thi3 seclion need not be completed if the permit is iRACf 25 BLOCK LOT NO. �:� MAP BOOK � �� PA PARCEL hundred dollars(5100)or less.) , . � TE� � • � -- owr�a Bramalea-Limited --No.850-1001- ��`�' oP 1/�3 / -3 I tenify ihal in the performanca of Ihe work for w �ch�hrs �� � I permi�is issued 1 shall_not employ any person in any monner • • � - - SVEUnt. -�---� � ----�-��� �� -�- - - -� ��a - --— AooRess 3151--A�rwa Ave. Su�te N-- - -- �2oec� CpNDITIONS � • � sa as to become s66�ect to the Workers Compens8rion laws. V . . ... ... . .., , ., ,.. ,, .. _ . .. .. . . . ., � ��•� �'��� A CHITCC�OR a_MeSB�.CA.. ......_. TEI. � ' .... ..�..�_� _1 RE_E. PROCESSED BY. . ...� _z�P ..92626- _. . �ote ... . ' ... �.APPIicaM�.. .. , ��.. � . _ DISiRICT__. GROUP NPE__... ._ FI . . I O ICE TO'APPLICANT: IF'afler makm this�Certi(imte 0( ENGINEER RI N0� - /� �pN 'U I f prioh, yau'�shoold betome sob�ect'-to�the Workers' . . �( _ /�/ ��.��' ;�y i 9 � Compensotion prowsions oF the Lobor Code,`you musf forth• qppRE55 � -� ��-"���-� =%� �-- ---�- jSd' - - �--- -Q' wifh Comply•with Su[h�provisiolls o� fhis ermit shall be -����-�- - TEL. STATISTICAL CV'.SSIFICATION - A7T. CONOp.�- :Z deemed reL'CE SED CONTRACTORS DECLARAT �ONTRaCiOR Bramal ea Cal i f. No.850-1001 ��. � .. _-' -. _._ ... .. --- - . -'. - ' .--- �---���. RASS NO. � DWELL UNITS � ION�., �, .._ , ..... .._. . - - - �.--��--__ -_. ----uc:— - � I heieby affirm that I am licensed under provisions of Chop�er 9 ADDRESS 3151 A�rwa AVQ. N r,o. 409610 I (commenting with Section 7000)of Division 3 of rhe Business and ._ �i�, � ��R'�'�P � ��" - � __ . _. _.. ._ ...- - - _�_-- --. . ......� . . _-'- Professioni Code,and niy litense is in full force and effect. CITY COSta M2Sd CA C1A55 B -�---eK,���-'�` � '- '-'���-�-VALIDAT�ON" -� . . . . . . � . , ,�.., . .., ' $p,Fi. NO.OF NO OF CHECK_, "��J U �, 'A ' � ' 409610 �.. . ���cia5s _ UcenseNom6ei B - ��' �� SIZE 1637 S70RIE5 2 ���FAMILIES 1�� - ONE , � . . �� V W _.. - r•� •2 . .,B � - Date. . . • _ ._... DESCRI t OF ORK-'._. 2ZC./ -------�-•-- NEW._...� sA AT�N �. ConlroUor T'dRld�Ea� Cd�1'F � ` A�D � P � e g 2 p 3 � .. . . ❑I am exampr under Sec. -- --$l ll l e Fam�1 --Resldence--.- -- --.- ,'— .. ... . ..:.... ....... ..,.� .. , ALTER � � T - . . . . .. . � . , �.��3�� 8.8P.C.ior Ihis reoson '---. 1 fl REPniR-❑ _.s —' ._-. � ._._..1_ .. .:- ------°-?.L� c�.-'. . ._.._. .... .__._. __.._. ... •, USE OF � . �. � , rS ... Date: DF1NOl ❑ � .__.''_ 0 C._� 9_`_.�6 - . / EXISTING BLDG. 110�1e .' �-- 5 _���nn G�YJ�-.�L....�---� - flNAL OWNER-BUILDER DECIARATION A�PR NTT . _ _ � NO_85O-I.00Z _.DATE� _ � _�� � �� --IherebyaffirmthatlamexemptfromtheContractor'sLicense AD�RE55 3151 Airwa AV@. N. COStd �"�25d' ' � �•�� ^: " � Law for the follawing reosbn�(Section 7031.5,Businesz and F�NA� . : �O S�.�A_ .� .-Professions tode)t" '. ....�_.. _...._... . . ._'_ '_'_.. R N _- By. ,. . _ ., . ' I, as owner of the ro er y P Y � eUitoirlG � _ ��� , �. ..\ � �.•.�• •.� � •,i �, p p y, or m em lo ees with qooRESS . .._.._ - � wages as Iheir sole compensation,will do the work and `� , - I �i the sfrutf�re is nol in�ended or offered for sale(Section ����TY � 4 �l.'5 Q .... -`--7044,Business and Professionz CodeJ: -- ._.... '—" MOVING' �------ -...._. .- ...` -� ---TEt.-..."... - . � ' - � - '. _ . '�t�±- -'..-._.. .... � I,as owner oF the properly,om exclusively con�mcting CONTRaC70R . � NO. -'��-- �`-'- o a t^p (`�.- ' - �with Ikensed commcmrs ta-wnstruct the project-(Sec- . .__.. ___.-.--_______.-_.- '_..---._- -. . ._.---.. .. ; - ' -'-_-.-. -. -..- � - -- . 4� � tion 7044,Business and Professions Code). A�DeE55 ' ' 0 G 1 9—8 6 � .._..._ REOUIRED... iOlAlSEiBACK FR M. %I . '-_ . -.-- -_ _--. "'--+- ' ' .;. ."-". _... ....- --' �-' � "-- �CONSTRl1CTI0N LENDING AGENCY"--- -� � SET BnCK -YAR�� �INJY " pRpp.LiNE wiorH � I hereby afiirm that ihere is a canstrudion lending a9ency(or FeONT � � ' �-�- � � ' � the performance-af the work(orwhith�this pe�mif is-i3sued "--- -'P.t.--..- -'--- ----'---`-��----'�-'—'--� --"'- --------._ ._..:.__. .. _,__�._.. _. -_. __ . _ ___ . (Set.3097,Civ.C.). SIDE � ,, ' . , _. . .. ..._' "_._. 7.L .. ._. ._... .. .. .'__ _.... � .._ _ _ _ .._ _ _. Toronto""Dominion BanK— � --- � �- � Lender's Name q p 'I � ' : ansome . Ul .GD�.Q -- PermirFee'- ��+Ref.N . . . .. . . . '--- F.C:Fee E - T'�� . . .. . .. Lender'sAddress�n�.FS"'ahS�'SCO•� CA.� 9��04 � , - ��� . � . . .{. I7 ' �. . . �� .. -_I certify lhaf I have reod Ihis appbmtion ond srare ihm the _._-' d�'NJJf----ll�-.�_._.._ise�oocaFee�--._�0-`�_.:. ior�q aiC M ��- -�'----�-- . ..-. .-- � =- "�-� obove informafion is torcecl.I agree 10 comply with all Covnry lo�mngonon Fea /��Q � , - .,_ordinances and Stale lawe relating to bvilding tonstrutlion, _. �.. __.. ioral Fee�--�----/�+-�'�-: �IDMA Perm.M - - � ond here6y authorize represeMo�ives oi this County to enter � , � _upon Ihe obove•mentio ed p o r for Inspection p�rposes. �d � " , --� --- . __ _ ___ _ _.._.._�.a.«��r_]��- --- - __ - . .. _ _ _. -:_ . i � � ��� SEE REVERSE FOR EXPLANATORY UNGUIIGP � _.-' SignoNre of Applrtant orAgen7 - ....."'J'Dote" "...' _ `_ __ _.___' . '_._ .-�- ) � � : �•O� , _ _ o �o . _ _ `-, � � ' _.T_ .__• .�.. ;�� 'D.....�. ...�1 � O l� T r.. .�9� �p 0. 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