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1198A 1199A
WORKERS'COMPENSATION DECLARATION I hereby offirm �ha,� ha�e a�e,,��f��a,e of�o�5e�,�o se�f APPLICATION FOR BUILDING PERMIT ins�re,or o cerlificofe of Workers'Compensation Insurance, �� or a ter�ified copy Ihereof($ec.3800,Lab.C.) Poi;�v,vo.61WBMX75 @€mpony Hartford Group COUNTY OF LOS ANGELES BUILDING ANQ SAFETY � Ce�rfied copy is hereby fu��rshed. FOR APPLICANT TO FILL IN Bu��o�N�' g36 S. Whi tecl iff Drive ADDRE55 ❑ Certified copy is filed with the counly building inspeu BUIIDING fiondepprlment. A�DRE55 936 S. Wh1t2C11ff D1^lVe ppe 7_24-87 APP''con' Bramalea Calif. arr D•B• Hills Z�P iaAUTv D.B. Hills CERTIFICATE OF EXEMPTION FROM WORKERS' NO.oF etoGs. NEnResi COMPENSATION INSURANCE SIZE OF LOT NOW ON lOT CROSS ST. (This se[tion need nof 6e completed i4 ihe permit is for one TRACi 42575 BLOCK lOT NO. 1$ � ASSESSOR hund�ed dollars($100)or less.) MAP 600K PAGE PARCEI iEL US ONE N�4P J �` �L 1 certify Ihat in the performance of the work for which this OWNER O. — �4:J� NO. !1 T��T � permit is issued,I sholl not employ ony person in any monner 3151 Ai rwa Ave. #N e��Od c� SPECIAL p„ So as to bemme su6jecl fo Ihe Workers'Compensation Laws. � ADDRESS .y e CONOITIONS � Dole Applicont _ CiiY COStd Mesa zia 92626 � ' TICE 10 APPLICANT� If, a4ter making ihis Cerlificate of ARCHITECTOR Aram Bassenian ?E�� 752-1864 DISTRICi GROUP ONST Z��E PROCESSEDBY � �m tion, ENGINEER NO. p you shoold become sub�ect lo the Workers' A .j? t�!] (/`i� �ompensation pro��sio�s o4 the labo�Code,you musl forfh- qDDRE55 3990 Westerl y P1 ace 7i'1�0 !v f(\�-� �i'`� ) � with comply with such provisions or ihis permit shall 6e tEL STATISTICAL CASSIFICATION APT. CONDO. N deemed revoked. � CONTRACTOR � B NO. �7 I LICENSED CONTRACTORS DECLARATION LIC. CLA55 N0. �WELL.UNITS� 1 hereby affirm ihaf I om licensed under provisions Of Chap�er 9 , ADDRE55 No.� 409610 (commenang wirh Section 7000)of�ivision 3 of Ihe 6usiness and ��� SF6VER MAP Professions Code,and my license is in full force and effect. CITY CtA55 B BK � VALIDATION SQ.F. -NO.OF NO.OF CHECK ' u�e„ge N„mbe, 409610 u�.ciass B ` s¢e�— STORIES 2 FnMiuEs 1 oNe . � VALUATION COntrtltlor OIB Date _ ' DESCRIPTION OF WORK NEW s � ADD � � �I am exempf under Sea 5FR � ALTER B.BP.C.for this reason PLAN 26 R REPAIR ❑ S r��j��� ='.'! 'j N,ti�1 Dafe: USE OF DEMOL ❑ h' p c " "7� � '� EXISTING B�DG. = Signature � AP�pgAN7� Bramal ea Cdl l f. nio. 850-100.1 F�NA� �,/ � I �`C�. 8.9 3 I OWNER-BUII�ER DECLARATION DATE t k�;�� ! I hereby affirm thoi I am exempt from tha Controctor's License � ��f��i�z T } Law for ihe f�llowing reason(Section 7031.5, Business ond ADDRE55 3151 Airwa Ave. #N Costa Mesa FINAL f Professions Code): PRE E T BY ,��'-C�"� C�,;��G.�.�� i � BUILDING } I, as owner of 1he property, or my employees with ADDRESS wages as their sole compensat�on,will do the work and , � the struciure is nm intended or affered for sale(Section iOCntiTv 7044,Business and Professions Code�. MOVMG 7E1. M � I,as owner of ihe properry,am exdusively connacting CONTRACTOR NO. �;•I � (��F� with licensed con�rotlors to constryct fhe projecl(Sec- �' qoDRE55 � � tion 7044.Business and Professlons Code). }'• � o e o � CONSTRUCTIDN LENDING AGENCY SEQ&4CK YARD HWV TOTApROP.IINE WIDTH � � ���G'� � I hereby affi�m tha�there�s a construction lendin9 agency for _ FRONT the performpnce of the work for whith ihis permit is issued P,l. s ���,F�,�_c (Sec.3097,Civ.C.). - SIDE - Lender's Nome �7 Toronto Domi nion Bank P` n 8 2 8-8 7 P.G Fee 5 �� Permit Fee �/..S�:.sY% �DMA Ref.p `' Lender'sAddrass San Francisco, Cd�lf. ' 3 I certify ihat I hava read fhis applimtion and etafe thot the 7 •� Issuance Fae l�•50 LDMA P/C 8 abova information is correcr.I agree to comply with all Counry �,,,,a���o�ion Fea a�A�€--�q �,('" ordinoncas and Stote laws ralatin to building construclion, 9 rotal Fae }'�'��'"'°'` LDMA Perm.k and hereb a th rize r rese ta� as of this Co nty to enter � � �po e o entio d pr p ty for inspect�on p poses. I ,� . SE!REV@RSE FOq EXPLANAfORY LANGUAGE �~ SI n ure t Applicanr or Agent Da a � ... -, —--- ---� ,� _.. _. _. _.�.. _._ _._. _.. ._. _!.... _..__ .. ... _ _ _ � �, v � --; _�.; _ _ - - - - -,-- ---w -: .,�_ � �_. „ _.�.- --� � ; , � ���. .L.\ � . � ' . .0 ��7 . f� �I � . ' i '_ � � , ' � � � � 1,�( �, i . • ' : � � � � � � �} � ; .. � � i . ; � 'i ; ; ,' I i. � ( << 1 � � �� � ;r„ . 7_ �' , ;i �� ; � ,� i: i, ;'i( � i `, j � . i —. . — � '; .` � t< , ' ... i � E At�,� �' . � ,� � ' � ., � .. �� � f � vi �d � , � � ;.. ;k g . ' � c: _ � n ! � � ... 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