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0806A 0807A
� _.. . .... . _-- �_ __._ _� ._ __. _ ._ ... _-------- _---- . __ __--- - WORKERS'COMPENSATIONDECIARATION , "-"� � ' � � � . � J'� � ^ '� �� ��' '�'�' i . ' ,. . � . . , . . . --'.'.,....._.__.._ .. . . _ � . _ . _ . ,I hereby afFrm that 1 bave a certi(ito�e o(mnsent to,self � . insure;oracertifitateofWorkers'Compensalionlnsurante, __ _ _ __� APPLICATION-�FO-R�.,BUILDIN�G�PERMIT�-� ' ar a cert�iied copy thereof�Sea 3800,lab.C.) ` ' " � COUNTY OF LOS ANGELES �j BUILDING AND SAFETY � � . . . ., , . , • 61WETX799�om � Hartford Gro�n ` � ��-- � " � .� Policy No. pa y �--- -- - ��--' BUILDING � Cer�ified topyii hereby furmshed , FOR APPLICANT O FILL IN ADDRE55 ��6� � Cerfified copy is�filed wllh�Fie[ounty building�in'speo- �- BUaDMG 1 � /.� � ' ��tion deparlmenf. �' � � � � . ADDRESS �v �� . .,•. . . ... .,.,. .�f . ,�//�_ _ . _ ._ _ .. . . . .. .____... .. _ _. . Dore�'z��APpiicont �,}��lC-cf- ,'^�',_(-�{J�7'�' a�v Diamond Bar zir iocnuiv ' �- CERTIFICATEOFEXEIvIPTIONfROMWORKERS C�".�1 P� ----. . . . . -�NO:OFBL�GS. . . .....__, NEAREST.--- ' ....+.- __._. __ .. , - . __ .. . . _. _..__ ,_._ ..._.. . -. �' � � COMPENSATION INSURANCE"�� � � S�ZE OF LOT NOW ON lOT CROSS ST. ._ r (ihis seclion�need not be tompleted if the permit is(or one - -- s ---------�-- �-�-- ^r�-- ASSESSOR,..�;�„ - . ' ""' ' .._'.." . ._- . .. hondred dollars SI00 or less. - . TRAC7 -.! BIOCK lOT NO. � MAD BOOK� � � � PAGE. PARCFL 0 on erson�man � _ U ZONE �+P I certif� ihor'n ihe erformance of the work for whith�this OWNEa- m � � --'��"NO = -�- �1�� pp. : ��r 7j �/ � --� �` svecini _ _.... ..... . ..._ . .. _ . ' _ 'r permit�s Issued,I Shoil nol empl y y p � y monner _, � ADDRE55-� ' - " ---- --- CONDITIONS � �V so�as to become subject fo the Workers'Compensatlon Laws. ..�. . . . . . .. . .. . . . „ ,.; ..,.,. . �ITY_. " _ '"'"�_ZIP.._ _"' " "'—"_".._ .,.._... ............ .. ._.. ___. ...00 . .. . _, . �., . .__. . . - .� . .. .. . Da1e. .� . �Applicont ' . . . -..' � TEI. ��� I �ICE'TO APPLICANT. If, ofler making this CertiFicale o( ARCHITECTOR . � � _DISTRIC(__ .GROVP NPE. . _._ _F1RE .,.,PROCESSEDBY ; /��pllo�; yoo should becoma subject ta the Workers � ��--- ENGINEER - � Cp1ySj � �E �6 - / fA 1/! ' ��� ,W Compensaiion provisions of tha lobor Code,yovmvsiior�h ADCRESS 3990 Westerl Pl ace SU1 te �170 -�--�(i�--- Y' �--�� � ��� ����-�- �y UCENSED CONTRACTORS OE['his,�permil sholl be -�-��- - TEI. STATISTIUL CIASSIFICaTION APT. CONDo. ��� wilh comply�wiih suth provnions or , dommencnoweh5ection7000 ofDiwSio ��NTRACTORBY�lIl�d�ea Cd�lf. flo 85�-10�1 ___ _ _ - .. . . . - LARATION�. . ..�.� . .._. _._. . . . _... . ....L�C . '_ _ . : CtA55 NO. � DYJEL(.UNITS� I hereby aifirm that I om litensed under rovisiom oi Chopler 9 AooRess3151 Ai rwa- Ave. N NO 404610 ' ��R�P . , ( 'g ' ) n 3 oi Ihe Business and __ _ � � ., '_'. . . _ . _ .. UC. � . ._ � � Prolessions Code,and my lirense is in full force ond�effect. CITY COStd Mesa,"CA. � cu55 B -- eK. -pG � _�' -- � -� �VAUDATION""'" ' � .. . „. .. .. .. ... ' '_'.�. SQ.FT: ' .�NO.OF. . ....._. NO.OF_, CHECK ' . ��� � SIZE STORIES FAMILIES - ONE�� , trcense Numbe�— B � __VALUATtON � - " ' �n��� 6 A 409610' • u�cia�= .. . . _ . .. ,w, . , , ---._ . . co�,�o�;o;. Bramal .a Cal i f.na�e' ' : . ' - -- oescR�Pr�or,o woeK-- ✓ -- - ---" A o O f ��� 7�'� {�• • •a 2 1 �I am eaempt under Sec. -` -- - � F Ifll� -Re51 d211C2------`- ALTER ❑ , � , � . ..., i 32Q4.:1,. - _ _ , �; B.BP.C.for this reason N2W C0�5 1"UCtI Ofl REPAIR.Q -S " - - '' - -- ` •- - ^ �� -' .___ � •�2"Q�1 � , ,. us�oF --- ___ :_ o �( �°F � Ex�sT�Nc e�oc. none oe�oi 0 8 1 9=S 6 _ . . ..� � 'Y� ' 1 APMIUNT TEL. .��� °_ � PRINT Bruce L. Ahbe N� $ - ' DA E`- OWNER.BWLDERDECLARATION .,. .�-u��- .- -"..' ..._.__..__._ _ . � �. '-. . - --'� --'� �' -- �---- -. . . . . . _ ._ � . . -I hereby affirm thot 1 om ezempt Irom the Conrcotror's Litense AooaESS 3151 Ai rwa AV2. N Costa Mesa - �� � �� � `��' � law for 1he following reason(Secudn 7031.5 Business and ' FlNAI _ ' _,_.Sy {� r�n .'PfOfE5570n5 CodB�: .. . _ .. ... •..�_ . -•..._ _ _. .- PRE NT . . . . .. . O Ci Q�/ /t ' .. BUILDING . , � �� 1, os owner ot tha properly,or my empioyees witb _ _ AD�RESS _ .._.. ,_�_. . -- . � - i wnges os 1h?ir sole cemp�rtsarion,will do tbc work and � . *'• .. tha structwe is no1 imended or affered for sala(Seuion loUuiiY � � . ._--------- - -- Te�. - ---._, , -. ._._ 1. F.I °5 ,9,�0 > > - - --�7044,Business and Professions Code.� --�� -�-���� ' ��"-- MOViNG NO. ' _ CONTRAROR -. _.�.` _.; s . . � I,as owner of Iha property,am ekdusively contracting ---_-- - .-,.r..� '-_ " p n,�� T� ' _.---... _ . � ._ .. --�-._-.._.__ - .___.. .-- -with-licensed contraclors to[onsiruct-the projecl��Sec- � ���- ADDRE55 � , � �'G�`''i': tion 70dd,Business and P�ofessions Code). � ` �-'• ' ' � '�� ' __ .._ _REQUIREO_ - .._fOTAI SEiBACK M I T.. .. .. .._.._.._.:. .. '._ ._. :.. - ' ,'_'l � CONSTRUCTION LENDING AGENCY'-'-"-�-�-� '-�-�-�' sei encK YARD�- MVVY� PROP.LINE wi�iH � �-��-9`S� _��. i_.; . ,.� .� ..,; . ; I hereby offirm tha��here is a conshuction lending agency for fRONt � �. � _ . � ..the performonte o(the work�For whith Ihis permit is issued � - -P.t-^_.- ..-- ---'- --..-'-�._.._._..... ._ __., _.' "___".'_-'._ .. .---..--. - .._.......---- - i � (Sec.3097,Civ,C.). SIDE - ' �� . � _.._ . - .- . _ _.._ _... . P.L . .__..__ __._. ._ .. . _. .._..._._. ._ .. I _.. .. _ _ '".... . . . . ._. . ti . . • . lender's Name Toronto �ominion Bank . .� . �� . .� �44 �Sansoroe St. ui te - .3.�p,�Ll_ -�5.��-� ' �or�nnn Rer.a . Lender's Address, �1'a115�1 SC0. - - P.0 Pee S --- Perm�i fea-- - � � "�� ..-' �._�_—TC{�9n1n4 ♦ y� ��+ .r--ff : , ' ..I cer�iiy lhat I have read�his opplimtivn and"state 7ho1 the -"_ - 'ql rT---N r!/�--'..... bsuon<e Fee- -- O•`�"�--' tDMA P/C#..-. - ----- ,. `..._-. . �:-- `�.� obove informa�lon is mrrect.I agree to comply with all CounN mves�gmio Fea N� � � _ ,., . ordinanms and State laws relating to buildin9 construcflon, ._....__ _"_'_..__ ._... :._. To�ol Fee-..-- .�• "'�-.-. LDMA Perm:N � - I ".'" ond hereby aurhoriza represeMatives of this Co�n1y to enter + , upon the above-mentio�ed prqp erry for InspeUion parpoees. ��yy�_� �___ _ _ _ .... (��� /�-.�,.'�..��� ryJ�y^ . __._._ . .. . _ .._ _.. __.___._. _'. ._.. . . _ ._ . _ \�Y!/wL�i�[ Ar,� � S�� . SEE REVERSF FOR EXPLANATORY LANGUAGE 3�� - ,. � :�. , , : \ �I \ • � . ._._.-Signature o1 Applirom or Agent �--�- - Da�e "_."-�. _'__'_-' -_' ._ ... 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