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1177A 1178A (5)
_ .. __. ... . . . . ... .. WORKERS'COMPENSATION DECIARATION � � �'�� , - I hereby oF���m thot I have.a terti(icote of�o�se�,ro,e�f � � APPLICATIO�N F�R BUILDING PERMIT � � � insure,or a certiFicate of Workeri Compensation Ins�rance, or o certifled copy thereof(Sec.3800,teb.C.)� � �� �� � � - COUNTY OF LOS ANGELES BUILDING.AND SAFETYi= "� - P❑olicyNo,�]J���pany Hartford Group� , : _ .. � � Certified copy is hereby fornished. FOR"APPLICANT TO FILL IN BunDiNG s N r ADDRESS � Certiiied copy ie filed w��h�he cou�y b��ld�ng�n4pec- ' eunowc Z43 2 East Nan C011Y't flon departmenf. A�DRESS ome 7-24-87 APPr,�o�, Bramalea Calif. cm D:B. Hi115 ziv iocauTr D.B. Hi11s CERTIFICATE OF EXEMPTION FROM WORKERS'' � � - � � � � NO.OF BLOGS. NEAREST _ . . .. _ ._ . - ' COMPENSATION INSIJRANCE' � SIZE OF l0T NOW ON LOT - CRO55 ST.� �This secflon need not be complefed if fhe permil is for one -� - 7RAtt 42575� � e�ocK l0T N0. 25 r RMp gOOK �� VAGE PARCEI hundred dollars(LIOO)or lesz.) OWNER Brama1 d dl'f. In .TNo.850-1 1 usezoNe nnna . I ce�tify that�in the performance of the work for which�this ��1, �� � —3 permif is issued,I shall not emp�oy any person in any manner nooRess 3151.Ai rway Ave.p �N SPECIAL - � .- so as fo betome subjetf to Ihe Worken'Compensation Laws. �� c7 CONDITIONS 0 ' ' Costa Mesa Z,P 92626 � oa,a aPPi�co�� . , . urv � �"OTICE i0 APPLICAM: If, after making-1his�Ceriificate of ARCHITECtOR TEI. �ISTRIQ GROUP NPE FIRE VROCESSEDBY O rmption, yCu'should 6ecome�subjecl lo�lhe Workers' ENGINEER Aram Bassenian r,o..752-1864 ` �p T, 20NE U compensotion provinions of the Labor Code,you must farth- pDDRE55 3990 Westerly Pl ace #1�� J 3 � w winc �omply wilh such provisions or this�permit shall be . I � ' �-� 0.' deemed revoked. � . . . � . TE�� STATISTICAL QASSIFICATION � APi. CONpp, fq CONTRACiOR O�B NO. UCENSED CONTRACTORS DECIARATION� - _ ��- - - - �-- �MSS NO. � W DWEIL UNITS � - z LIC. I hereby offirm that 1 am licensed under provisions of Chapter 9 nooRE55 .-•"� NO. ��R�P (mmmencing with$ection 7000)of Division 3 of the Busineu ond _ . ,-� _ . . _,_ . ���. Profensions Code,and my license is in fuli force ond eftetl. CIN Zt� CtA55 6 - BK----� --� �- VALIDATION � � � 4�961�' � 'B-' ' SIZE U— �STORI�ES 2 FAMI�S 1 � � CONEK� Licenee Numlier Ua Class' ' � � � �y� N� � _ VALUATION � O�B ' ' ' � � - � � ' � " �ESCRIPTION OF Wp2K ' - O S Controclor Dma ADD �I am exampt under Sac. - - -- ' � Al7ER ❑ �3,Z (� , �� � 7�7 A /_� ���� B.BP,C,for iliis reoson PLAN 24 REPAiR.❑ S t�• • • •2� USE OF .. ... - . - Da�a: �� DEMOL ❑ — . exisTiNc aioc. - f +3 7`a 7 5 Signarore APP��,NTT Bramalea �d�1 f. No.8 5 0-1 0 01 FINAL D� OWNER-BUILDER OECLARATION _, --�DATH ��9/�a • .3 7 5.7 5� I heroby afflrm�hat I am exempt from the CoMratlor's ltcense qoDrtE55 3151 Ai rwa AY2.� �N �OStd Mes � Law for ihe following reason(Section 7031.5,Business end y FlNAL � �g,2 8_8�7 Professians CadeJ: - - - � - � � � � 6y � � BWt01NG � . - � '- I, os owner of the property, or my amplayees with ADDRESS wages as their sole compensarton,will do the work and i�i TM � � the strocture h nof tmended or offared for sele(Sectton . , � � . � � 7044,fiu5iness and Professions Code). � � �� MOVING�'. --� - TEL.- �- � `1 � '�$A � I,as owner of fhe properfy,am exclusively conlracting CONTRAGTOR' NO. � . with I�censed tontracton to construct tha pro�ect(Set- " qD�RE55 � �• • ° • ' � • tion 70dA,8usinass and Profasilons Code). , ' ', ' � CONSTRUCTION LENDING AGENCY - � SETQBACK YARD HWY T�TAp OP.L�NE WIDTH � ' � � ��4��O I hereby effirm that there Is a mnstrucflon lendfng agency fot FkOnIT � • � � � the performonce of the work for which this permit ie iswed P.t.� - - �" ' ��� ' � ' .•'°b u���� (Sec.3097,Civ.C.�. StDE - P.�. . � • �' 0&28-87 tende�'s Name 7 � � San Francisco, Cal�l.. P.C.FeeS PermirFae _ ��Raf.N ;-. ,.;i Lender i Address s ' I cerHfy thaf I have read thls application and state fhat the , 75•�� Ivuance Fee 10•50 LpMA p/C N obove in�ormation is corract.I agree fo tomply with all Coun}y Investigation Fee ord�nonces and Srate lows elating to building construtlion, . torol Fee - ����. �pFnn perm.N ond hereby authoriz repr ent iv s of this Cou ty to e ter upon fha ab e- e ioned r p � for inspectia purpo es. �� „, � ,, . , , � , l � SEE REVERSE FOR EXPLANATORY LANGUAGE ignoNre of p i nl or Agen� -� pate .. - . . � . . . . - --. . . . . . . ..... .�`' i . . _ ._ , . � � n= O O J T N O NO D .O (1� �`/7_ _G) _Gl ti- $-.. .{. 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