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' Y . . ... � P , . . "'. '_. .. ..__ __.._ ...._..�._.."""'._.__...,_.__._. _..._.._ . ..... . .,__ ..... . __�____-�. . � WORKER5.COMPENSATION DECLARATION -� -� � - � � -� �- � � �- � � PY � .( . ..' , _.�.. . _. . . r �_ .: �. , Po„� N 61WETX799 Hartf d G se1/ APPLtCATIQN��FOR�:BUILDING-PERMI� � orharcertilledrm�thahe eof Sec:c3800cLoboC.consem tonce, insu e,or a certificara o(Workers'Com ensation Insuro ' ' ' -__ ... _ . ._ . ` y o. �o m p o n y O l' Y O Up COUNTY OF LOS ANGELES . BUILDING AN�SAFETY __ .. . - - . \ � Cerrified copy7s hereby fu�Nshed. � ', FOR APPLICANT TO FILL IN gun�iNG � � AWRESS JO(� y�,� � .-Certified copy is Filed with the county buJdmg inspeo-""��---- BWLDiNG ; - `fion deporlmenl. "���•: - � -<� ADORESS 1085 South LOn view � � � , : _ _ ... _ __. .. .__. � oa�a.. -�����Appikont fITY Diamond Bar z�P �ocAurv i . � '.'� �CERTIFICATEOFEXEh1PTIONFROMWORKERS"`'.�• . -. �. -..-...-- �"' �--NO:OFBlDGS..._.-.---- --� MFARfST�--__�.__._.._._.. _........� ._....._...._.__...._._.._... . •- � � � •COMPENSATION MSURANCE�� ' + SIZE OF LOT NOW ON LOi � GROSS Si.., ' .<•, . ,.,- , , _ :...... �This�settion need not be mmpleted if fha permit'is for'one -.--- -- -- -.-.-.._._- .._.._._._. � ,q55E55pR. ....... . _��._ . ,: .•..• . ti��d�ea aoua�5�s�oo�o.ie55.�;:, TRAcr 4256R_, a�«K LOT NO. � A44P BOOK PAGE PARCEL ' ' ' ' ' .. iEL . :', . ' � ' ' � owraea Bramalea-Limlted -- No85 10�1 ' � o"E """° - �1 certify_thal in Ihe performance o(tha work for whic6 this D NO. � ���3 / �,� � � � � parmi�is issued,I shall not employ 6ny person In ony manner • • �r� SVECIAI� ----�. - - �- � � �� �--- - O}. so�os to become subject'to IRe Workers'Compensafion laws. ��- ADDRE55�--3151-A1 Y'Wd -AVE�r��--SU 1 te'N� �� �d8� CONDITIONS Q . . ..., :,. ,, ,':; arr Costa.P1esa�--�A_. .. __ z�P_92526- - ._ - --_._ _:__.., � _ .� � Date' `� APPLcanl. ' . .' "-"- i i ' , . .CC � ' �CE TO ACPLICANi.If;Offer-�moking�thii�Certi(icofa of ARCHITECTOR TEt, DISTRICi GROUP: iVPE .FIRE P20CESSEOBY.._ ;� � '"' �nptton,'yov'should become subjed��to'Ihe"Workers' -'--�- ENGiNEER Aram Bassenian Ntl.52-1864 � - � COn�y -��� -� 20NE- � CompensatSon provmions af fhe La6or Code,you muv forth- . 1 r�_ Q�-3, - " •�++ ; with comply.with�suth�piovisiens or.this.permit:hall be AeDriE55 39 Westerl Place $Ult@_1�� �- � - - ..� . _..__. .. . ,y i deemed revoked.. ... � � . ' TE�� � STATISTICAL CLASSiFKAT10N � APL CONOp �� �Z � '"�„' •'' CONTRACTOR � NO.H �1 1 LICENSEDCONTRACTORSDECLARATION .-,.,�. - - .. ---- - ' --'�'- '- -_..._ _ _ ....._.. .- �- �-�- �-- .- � -.__ . ..-- i -���,-� C1A55 NO. DWFII.UNITS I hereby offirm�har I am licensed vnder provisions of Chopte�9 ADDRESS 3151 Ai rwa Ave. �N No. 4�J9610 � (commenc'ng wiih Section 7000)ot D v sion 3 of�he Bosiness and . .. SEWER hua �. � �� ' , ._ .. .- - _ - ._. ..- —. . ....._.LIC..__-_ -. Aofesiions Code,and my fcense is n f Il lorca d d effecl. CITV C.OStd Mesa r.A CV+SS B ---"� BK.'--� - � - - -��- -- -- . ... .. .�.... . .. . .. .......: �.� _""" 50.FT. .,NO.OF__ "_._._ NO.OF "1__. . CHEIX , .•. T ON 4ALIDA 1 licenseNumber " � ' Lc.�Closs � ' SIZE 2542 sToeies 2 FAMILIES oNe , , , � , .. . . : .� w `•Q i 9.f�;�.:.. . " . :. � ..- . ,. .-.-. DESCRIPfION Of WORK' �-'�- - - G .g N��� a / ;�� __. . Contmcloi ' � � ••. - Date � �.� ...�._ � � � µ�_�.�,� �- . ' t 2.�. -- VA ATION. .; ' � _ s � /� U"" . ,. . ' �Iomexemplunder5ec -•�- Slll le...Famil ..Residence__.._._. Aoo . , � . ... __...-_.❑ ,. . .. �:� B.BP.0 for�h�s reason � N2YJ Construction ALTFR - - `��1���•-'r . ....�� RFPAIR..a S_' ___.�__. .'.. .. .� . . ' _ _' a � � • _.,_ _ .. _.._ .. _ ._.._. .. � �� USEOF . 'J . I c� / Date•��� � �� E%i57iNG BtDG. n DEMOL ❑ ' � ` � -' _ Signoture � I�J'LH..'1�--- �rf?'4+fd��- � nraiCnNi .- teL. FIHAL -..._-� - C,r� � � - O ER-BUILDER DECIARATION � ve�M , b NO.HSO-LOOZ � .__DATE-- L� �7-' -����- -_.-•-_ - -.. . __ � fl - �. -II- ..-. � ._. . _... . _ ._-' . . . . . � _ _ : -I h e r e b y a f f i r m r h a t I a m e x e m p r f r o m r h e C o n r r a c r o r s l t c e n s e AooREu 3151 ai rwa Ave. N Costa Mesa � law for the following�reoion(Section 7031.5,Business and Y FINAC ' ` - ' ' '� � �' ` � . � ._._. .. -'-- -. __..._ . _ y _ , � .. . _ - L 7 .�A. ; "'Pro/essions Code):� ' PttE NT S . . .. ���---ttt���� , BUILDING , , Q � �p I,as owner oI fhe properfy. Or my employees wtlh ADDRE55 ."___. _...__....__-,.._:.. ;._ . .- :. r.i •�e-.o'�e..�._-: .r ��wages os Iheir sole compensafion,will do the work ond� - . , '� the strutture is not in�ended or offered for sole(Section ��ULiTY � ' � . �' � �. _704G,'Business ond Profeselons Code).-.-'... . . -"._ MOVING_ . .._....-....__..___.._... _. TEC "-..'_'_ .. ; _" '._ ...._._.. . ,_.. :. _.. . ._.� e b_F��n�._.� I,03 oWner of the property,am e%CIUS�vBIy Contracting CONTRACf04 NO. � � � , ;. � ' �. . _. ___ _ _..._._..._._.. __...'____ _........___•_._: .._. _ ...._�...._ - . �`'- ... �� wi�h-Ilcensed conirocton to construer rhe�projecr(Sec-�--- � � -- •6 ,Q Q ci..� . lion 7044,B�siness and P�oles:ions Code). A�oRE55 . _ n n - -" '-- REQUIRED_. TOiAtSETBACKFR M._ .. xl i. - .. . ___ .....:.. �i .' ..,__1 '.'_ ._� _O.('._� 9.`HG._.�; " �-CONSTRUC110N IENDING-AGENCY"� """--"�"" '- ' �Set BnCK -YARD�- HWY- - PROP.uNE wiorH � -,�` � I hereby allirm�hat rhera is o constroc�ion lending agency for FeON� � �� � � � -1ha performance of the wak-for-which this permit is issued ...-..... .V.L.-.-.--.. __. _.._ ...._ ._ _._._. .._._.___.._. _�_-i .__.....___ ..__. :."._�_., . ."�"_ "__.____ -.. (Sec.3097.Civ.C.). '-" SIDE ' . . . � . . P.L. � -�. . .- �� . ._.__.. . . __, . .. , . �Lender'sName Tronoto�Dominion�Bank . .-__. . --. . -.-..--.— - --.._--.--� . -�'�� �� � . ansome . uj q� / � �otiv,aec a _ , : , , . : . - -.— P.C.Fee S-��A����.. -. Permit Fee- -!p� �--� lender's Address dtl PdI151 SC0:�C y �� ` - --��. ��""" c--�t i . I certify�hat t have reod�his applitntion and state thm the e�v/ ..._�S'.6'v - issoance Fee— .J-"-.-. LDMA P/C N.....--".__.. , �� � '��� _....__. . _. .. ... ._ . .� a va in ormation is carred.I ogree fo comply with all County inves+�gaeon Fee /'� • � . _ordinances and Sta1e laws relating ro buiiding tonslruuion, (�' ' .���,� . _._._ _.....___...___'_.' . -- ToMiFee�-�1.7����� �- LDMA�Perm.-N.___...._.._ _._ '__..._..___. . . ,..:.�_�_.,' and hereby authorize rep�esentativez of this County b enrer� '`� upon tha obove-mentioned properfy for inspection purposes. � - �_ _ � , �� -. ... _ ..__ f� _._ .. _ � _ ' '._..� _..' . _ " . ._. . . d �� {(�� 7��g6 ---� SEE REVERSE FOR E%IANA� � '`� � � ��"' _-'.. �� .�� , . •` R ��- � I _ __ _ '.'.$ignoruieofApplf nrorAg<n�._.�.. Dota_. . . ... ... . ._.. � "'_' _ �� 1..� . ._ _. .. . . �< . .�Z : . _ _. . ,n� I _ ,,) (_ �� �.,` . ..,. ' . __. _ . - : . _ ., i � � ... . .. .,._. ' , , . _� - - -�- r T N _r Q. O -^�- ��" _�'' O.. _�_ ..O- i O- _ -� '-- ---' ... . 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