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0890A 0891A (4)
. .. .--- ------- - . _....._.._ ._._._ - WORKERS'COMPENSATIONDECLARATION .. . . . ,." .... . ... . ......... ......_...._ . _ _ _ .... .,; ... . .. -- -.--' / . . . ...--_.....-- ' . .. . , I.here6y o(firm �hot I have a ceriificate o(consent to self - � �J insura,oraterlificaleofWorkers'Compensation,�,�,o��e, APPLICATI�QN � FQR.BUILDING -PERMIT � - or a ceriified copy thereof(Sec.3600,Lab.C.) ' �� ' � " � - �� � COUNTY OF LOS ANGELES BUILDING AND SAFETY � � PolicyNo.61WETX799aom��y� : _ �Cer�ified co s here furnished�� BUILDiNG ;`/`/� Y. (Yi A ❑. PY' �' FOR APPLICANT TO FICL IN ADDRE55 �Y'y L ✓�L�.�-�C2v (� Ceilificd mpy is filed with ihe�count building ins eo- / BURDING � J�(� lion depar menl: � � ADORESS 24419 � Da�e��Applicont � CiTV Diamond Bar Z�p � LOCALITY ' � ' CERTIFICATE OF EXEMPTION FROM WORKERS'' � �� - - �-� - :--�� - NOr OF etoGS. � � r�nReSi.- .. . . __._ ___ _ . _ .__. „__ .. " � " �' COMPENSATION INSURANCE � S¢E OF l0T i NOw ON LOT CROSS 5T. ' � � (This�section�need no�be comple�ed if iha permit is for one / - - / ASSESSOR hundred dollors(5100)or less.). ;. . TRACT ✓ BLOCK LOT NO. '�J Mqp gppg � � � FAGE PARCEL ow�R Bramalea Limited No. 850-1001 ���Qj^� ""^" 1( y I terlify Ihat in Ihe performanca of the work fo�which this � Np, f I y �• :} pe�mif is issued,I shall not emplay ony person in any monner 57EGAL � � - -- � - -� 6. so as fo b�ecome subject to Ihe Workers'Compensation tuw:. � Aooaess�-�-3�5�- A1 PWd V �- " """" ��J CONDITIONS Q . . , u _ - - .. . , .. .. . Date � � Appliconl . .. .' .. . GITY. .. ZIP _ ' .- - � .� JICE TO APPLICANT: If,�of}er moking this Certificofe oF ARCHITECTOR 7Et. _ DISTRICT GROUP TYPE : FIRE PROCESSED 8Y �nption,'you shouid 6ecome sobject to'the Workers' ENGMEER NO. �p T: NE �O / f� v l:ompensation pravisions af�lhe Lobor Code,you m�st(orth- 3990 We � P� .j(� /�3 ur ADDRESS a ith comply with such provisions or this�pe�mit shall be � .N deemed�evoked.. ' .., .. � . TE�• 7 STATISTICAL C1A551FICATION AP. CONDp. .,Z ' ' CONTRACTOR NO.F3rjO-�OOI .�� . .. _ _ UCENSED CONTRACTORS DECLARATION ' - - �-LiC. -- . an55 iv0. � DWEiL UNITS—L n I hereby offirm Ihat I am licensed�nder provisions of Chop�er 9 ADDRES ryo. (commencing wHh Sec��on 7000)o(Division 3 ot the Bosiness and _._,_ .__ _���. SEwee hwa � Professions Code,ond my Ikense is in full forte ond effect Cit�' CL455 B � - BK � � � ' - � ' � VAIIDAiION -� 50.iT. NO.O Np,OF___ CHECK �ICenSeNUmbef '- A���1e � Li[.C�a55 g $IZE STORIES� FAMILIES� ONE . , . - , C� � .vawanoN _ NEW _ ', ' BPaffld�Ea'�Ca��lf�. ' '�, --� -� DESCR IQN FWORK- � -���' - �/�/ � � � Con�roUor � Daie ' s ,��� � � �G E 9.0 A A�D .._. � I am exempf under Sec. �� • � • • � . . ._ . ' . . ALTFR � . • • •G� B.BP.C.for this reason NQW Constructi o REPAIR ❑ s - ' -"- � e?(�.',(�� . .- � 1 .. . Oafe: E IST�ING BLDG. DEMOt ❑ • � J • n;;�CL,�.��c'_._ �� Sinnplurn ,� "' '-�'' APP�ICANT TEL. FINAL � ..� OV NEf1-B IDER DECLARATION �RiNT NO. - _ DATE �- -- � � -�� -- - 1 hereby affirm ihat I am exemp�from�he Contracror's license qDDRE55 3151 Ai rway Ave.,N� COStd Mesa � ���r 0—8 6--� - law(or the follawing re6san�Section 7031.5,Business ond FINAL� � � � ' � � ' . Profe'ssions Code):� " ' ' - - pRE NT 8y � - - � • '�] BwiowG . 5 I, os owner of Ihe properfy, or my employees with ADORESS ... wo9es as iheir sole compensorion,will do ihe work and � � - . the struclure is not in�ended or offe�ed for sole(Secrion ���ITY � - 7044,Business ond Professlans Code). - - ��-� -�-� MOVING'� � �-��� -- � -�--�-- TEt. -- ,-- � � � � � ��= � • . C'�9 1 A I,os owner of the property,am ezclusively conlratting CONTRAROR NO. � � , � �._ _ _... y.�w • • o , wuh ficensed mntrocrors to�consrrucr the Project(Seo- .. .- - - -.--.-. - . ... -. . - � - - --. .. . . . . . tion 7044,Business ond Professians Code�. ADDRE55 , c ,r , - - � � REQUIRED. .IOIAL SEiBACK FR M I I �G a G O - CONSTRUCTION LENDING AGENCY ' '� "� - - 5ET enCK YAeD� �HtVY PROP.UNE WIpTH �� �� �� - I here6y aHirm thal�hera is a tonslruc�ion lending agency for pkONT � . ��;,�Q G�_ ' _ i. � ..Iha performance of�he�work(or which Ihis permit is issued �- �- v.L. �-- . . . .-... .... . .... ....'- ''--- .._. . _ _ . . .--- ----.._._....._. .._ _.. ($eC.3097,Civ.C.). SIDE - � 0820.—&6 m _ . -- - -. . . _.. _._..._.. _. _._. _ _ . __ -- �.._ Lender'sNoma Toronfo Dominion�Bank� - , `? 144 SanSome St.�-SUi te 700 - r.c:rea s - .� 7:- oe,�„��Fe, vr77�S� �DMA Rel.p , . Lender's Address � � I.certi(y ihaf I have read Ihiz app icatian ond state of tha _._. _ . __ .. ._�.-rl� � Issuvnca Fee. �0'�� . LDMA P/C N �' -- . . �. �.. . . .._' . ._. _. obove informalion is correct.I ag�ee ro comply with all Counly Invesnganon Fee (�p .ordinancez and Stafe lows relating fo bvilding mnsiruction, ..___ To�ol Fee� �O p• � L�MA Perm.M -� - �� � � _. _._ .—.__.__ .' ._. . and here6y aufhorize represeMatives of this County to enter - ��--�� - � - � �� �, apon Ihe abov -meMl ned pro rl f r inspetfion porpos � . . .. _ . . . . ._ _ .. .. ..._' .' _ ___ _. _ _ - SEE REVERSE FOR E7fPLANATORY LANGUAGE �� ! -._... ar of Appll Agen . _ ._'Dofe" _ . _ _.._. ....' "_ ' ' . -._... . _ . ... . ... . .. .. .l. : . _ . _. _ _ .ni �• - _ Q 'o . T. :�' ,o ' ' . _�_ -� o � . �-u, ' o a- °. �< � t� � o g 9 � '� tu S� �O m ,� � p N n'v t�0. cfl .p ... C Q � O '�O � 3 0 � O r �, � i'7 i � N i , ,t� iP O , t0 7 �� �� i M N � „� , T � O 7 O O �D � O .�t,� $ Q M n Y' � ? �O � � 0� Q°� � /'7.. J O . 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