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1189A 1190A
I ; WORKERS'COMPENSATION DECLARATION � I he�e6y affirm ihot I have a cer�ificate of consent fo self APPLICATION FOR BUILDING PERMIT .. � �ZI insure,or a certificate of Warkers'Compensalion Insurance, ' or a certified copy ihereof(Sec.3800,Lab.C.) ; Poi;�YNo.61WBMX75�, Hartford Group COUNTY OF LOS ANGELES BUILDING AND SAPETY pany ( � Certitied copy is here6y fumished. FOR APPLICANT TO PILL IN euuo�rvG ' ADDRESS 4Z1 S. Whitecl iff Drive ; Cenified copy is filed with the county buliding inspeo- BUILDING i � tion deportmeni. ADDRE55 921 S". Whitecl iff Drive � oo�a 7-?4-R7 ApplicaM Rram�led ����f cirv D.B. Hi715 ZiP LOCALITY D.B. Hi11S � CERTIFICATE OF EXEMPTION FROM WORKERS' Np.OF BLDGS. NEAREST � COMPENSATIDN INSURANCE SIZE OF LOT NOW ON LOT CRQ55 ST. � (This section need not be completed if ihe permit is for one ASSESSOR hundred dollars($100)or less.� TRACT 42575 BLOCK LOT NO. �� MAP BOOK PAGE PARCEL Bramalea Cal if. Inc.TE`850-1D01 us oNe nv,P � I cerrify ihat in ihe performance of ihe work for which this OWNER � NO. �A ND l _ .3 • permit is issued,I shall noi employ any person in ony manner qDDRE55 3151 Ai rwa {�V2. �N �� SPECIAL ' � pso as to become subject to the Workers'Compensation Laws. � ��� CONDITIONS � U � Dofe Applicanf CITV QS't M Sd ZIP 2 26 � � ARCHITECT OR TE� DISTRICT GROU7 NPE FIRE PROCESSED BY C� '�TICE TO APPLICANT: If, afrer making this Certificate of Aram Bassenian �752-1864 �� T Z�NE U ENGINEER NO. � ,emption, you should become subject ro the Workers' �„_ p �ompensation provisions of the La6or Code,you must forth- qpDRE55 3990 Westerl Pl ace #1�� /!� ��� � �. W with romply wifh such provisions or this permit shall be TEI. SiAT15iICAL CLASSIFICA710N APT. C DO. N � deemad revoked. ��B � � CONTRACTOR NO. g LICENSED CONTRACTORS DECLARATION ��� CLA55 NO._ � DWEIL.UNi�S� � f I hereby affirm�hat I am�icensed under provisions of Chapter 9 ADORE55 No. 40�9610 3 (mmmencing wifh Saction 7000)of Divisioh 3 of the Business and ��� SEWER MAP Professions Code,and my�icense is in foll force and effect. CITY CLa55 YALIDATION j 54.FI,_ ' NO.OF NO.OF CHECK BK. PG. � Licensa Number 409610 Lic.Class g SIZE la STORIES Z FAMILIES 1 ONE VALUATION O�B pa�a DESCRIPTION OF WORK NEW � � Controctor � s � � �I om exempt under Sac. SFR ADD � ' ALTER � j 6.8P.C.for this reoson PLAN 22 ` REPAIR 0 s �����b?� .�="i 'i t�7�; � pp�e: USE OP DEMOI �� � I EXISTING BLDG. ❑ f; a 4 a`Z'� i $ig�afure APPLICANT TEL. FINAI ' - OWNER-BUILDERDECLARATION PRiNi Bramalea Calif. No. 850-1001 �{/ , r�'/' j :+,';7 �j,(�� � DATE „�w�:'.�,r I hareby affirm ihm 1 am exempl from rhe ConlraHor's Liceme 3151 Ai rway Ave., #N �OStd Mesa I law for�he following reason(Saction 7031.5,Businesa and AD�RE55 FINAL `/�' � � '-��7 �'�',��,�' Profesaions Code); !y a ZEr..c� � I, as owner of fhe properly, or my employaes with ADDRESS ����t���� �� wages as their sole compansation,will do the wark and ' �he structure is not intended or offered for sale(Setlian /OCALiiv � 7044,Business and Professions Code). nnOViNG 7EL. I� � I,as owner of Ihe property,am excluslvely coniracting N7RACTOR No. . :_1 "I 9,�Fl with licensed contrac�ors to construct the project(Sec- qoDRE55 '�i tion 7044,6osiness and Professions Code). ��a � a � e 1 �i CONSTRUCTION LENDING AGENCY SET�BACK �ARD HWY T�TApRpPA NE WIDTH '� I hereby affirm ihal lhere is a construction lending agency to� FRONT � '3�4�V U ���, the performance of the wo�k for which this permit is issued P.L. '. (Sec.3097,Civ.C.1. SiDE � a�r�:+ti ij W t; �i Lender's Nome Toronto Domi ni on Bank '` �q--p�� `� "'� p g 2�..g� P.C.Fee E `�".'�T�`� Permn Fee ��V ��Ref.# " Lender'sAddress 5an Francisco, Calif. ' � � I certify ihat I have read�his application and slate Ihat the .�� Issuance Fee � LDMA P/C# above informvtion is correct.I agree ro comply with all County Inves�iga��an Fee �//� ordinances and Slate lows reloting fo building tonstruction, ��rL��� IDiJ�A Perm,fl and hereby au horiz repres niatives of ihis County to enter iotol Fee '�, � upon f e b v -men e operty for inspec'on urposes. 1 In �$ J � , SEE REVE0.5E FOR EXPLANATORY LANGUAGE A ��y ', ra of Applicont or Age�� re - � � ...... ..... .. .. ...... . . . 4. �..._ _... __ .. .. - -- - - - —_ _ _ _. , . .... . . _._.. , . �._ ., ,. .. _...�" ., ., . � � i -: ; ( _ ' f -a ' 1 > �-.'� � :.� „ �4 ;, � . i ' I � � � . ,, . : � F ij . : �. � .. 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