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HomeMy WebLinkAbout0954A 0955A , , _._ _ ._._ . _ __ .. . .... _ __ _ _ _ ... .. _ _. ___-- .- - ' . WORKERS'�COMPENSATION DECLARATION �� � :' � � � -, 1 I . ...: ._.._ _._ .. . ,. . . . � . �I here6y afiirm that,l have a cerlifim�e of consent to 5e,f APPLICATION�� FOR -BUILDI NG PERMIT-- I insvre,or o cerfifimle of Workers'Compensdtion Insurance, , o�'a cer�ifed copy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolityNo61WETX799�om�;,Y Hartford�Group _ _ _ . .. . . . . -�. : � Cenified copy is he�eby fumished. FOR APPUCANT TO FILC IN suuo�r�G /�j GF"�'� �� ' ADDRE55 O � � Certified copy is filed with Ifie�county building inspeo - �- gURDiNG �/ � tion de a�rme . � � -�-- � � AooRess 1110 Sauth Hed ewood Court � '� Date���]r,�,PPIimN - � CIiY D1 Ill d ZIP � IOCAUTY �. . � . _._ . ... _... _ - NO.OF BLDGS. . _..._. . NEAREST . ._ .� . ._ . .._.., � CERTIFICATE OF EXEMPTION FROM WORKERS� � � �- � � � - 'COMPENSATION INSURANCE��'� , . - 51ZE OF LOT NOw ON lOi CROSS SL � (This sectian need not be comp�eted if the permit is for ane - - - e cc - �- - - -- -� - - - -- - - a55E5SOR - -- � .hondred dollars(5100)or less.) � . TRACT YZO VH . BLOCK l0T NO.� 43�'�.1 MqP BOOK� �: � PAGE PARCEL owr�R Bramalea Limited - nio. 850-1001 us NE nnnP 1 I[ertify thol in the perfoimante of the work(or whic6 Ihis f�� NO. � ��'✓ - } permil is issued,I shall not employ any person in any monner nooaess-3151-Ai rwa -Ave�—SU 1�t2-N---- SPECIAI --- - � - - � d so os to 6ecome subjedl to the Workers'Compensalion Laws. - � �O�D C'�ND�TIONS � � j p � . CITY- COSt(� Mesa, CA Z�p 92626_.._ o�s,R�a GROUP 7yPE FIRE PRO � v Daie ' � Applicant ' " � qRCMiiECTOR • iEt � . �IICE TO APPLICANT:�If, affer-meking ths Ce�hficale oi ENGIN�ER Aram Basseman Np�SZ-�HG4 � . CONST. ZONE �S�DgY -O ,,'nption, you should become su6ject to-the Worke s' ---- ' �, . , �1J Compensation provisions of ihe Labor Code,yoo must fonh- qoDaE55 3990 Westerl P�.� SU1 t@ ��� �� . �-3 _ �. . �� . 'ii with comply wiih such provizions o� Ihis permit shol� be- - - � � u� deemed�e�aked._ .. .�., �.. ._,.,. . ...... Bt'dmdl ed .Cdl l f TE�'850-1001 STATISTICAL ClA$$IFlCATION . � AP1. CONDO. � �� - CONTRACTOR NO. ___.______Y. P .P _.____ ._ . _ . ._ . - � LICENSED CONTRACTORS DECLARATION�---�------�- - • � - - � M55 NO: -�DWEIL UNi75- �� -� -��- - -� - 3151"Airwa Ave.,N No.409610 I hereb affirm that 1 am litensed�nder rovisions of Cha rer 9 ADDrte55 y ��R�P (rommencing wi7h Section 7000)o(D vision 3 0(fhe Businessand .. _ _., . _. ._.. .. __. -liC. - - � �. ; �. Professions Code,and my license is in full forca and effett [Itt COS'td M25d CA Ctn55 B -�----- BK:- -�--�: -� -- � - �� �Vq(�pATION -�- - S(].FT. NO.OF NO.OF; CHECK ' . , LicenseNumber 40Q610 --- u�.eio55 B size 1884 sToaies -2�-�--� FnMiues-� �1 --�� - oNe .- . � � �� � VALU TION .� '" DESCRIP ION OF WpRK-� N� e e c Contratror ramal ea r.d�1 f� Date � � / 9 � B � ADD S /o� ��__ . . .. _� Cl�,�ll.� �i om exempt under Sec. .- . • • • . . , a; ,� '.. , ALTER � 8.8P.C.for this reoson N2W Constructi on eErniR-❑ s " '- ' ' `1 Date:- u5e OF , I "J���,G.� ,. � EXIStING BLDG. NOr12 DEMOL Q � T_ � Signature � � aPR�Urvi 7EL FINAL ,I ,) ' " G;�`l.1 �� . O E -B IDER DEGLARATION PRin�i _ C' _ NO. - .-DATf . . ..-� - - ---- - _ -. �1 hereby affirm tha�I am exemp�from Ihe Contracror's licensa - �- � - - �.�' ` � . � �'F !O-'�':> . Law for tha following reasan(Settion 7031.5,Basiness and ADDRESS FINAL 1�`�`�� � � � � Professions Code): ' `� �' � - k �Y 1 -L� � � - - - - . -� BUII�iNG . . . . _ __. . . . � � .� _. . � . I, as owner of tha property, or my employees wiih A�DRE55 .� wages os their sole compensmion,will do the work and � -�- �_ � . �he s�roctu�e is nol intended or ofiered for sale(Secrion ����TY , � ' , :(��=��� � . - 7044,8usinetsandProfessionsCode).. . -.. ....� MOVING�- -- '---------'....------ - - TEC.-�---- - -.--- ---... . . .. ..- . : -'.•••� � � I,as owner of Ihe property,om e*dusively contracring ' CONiRaCTOR NO. � � �• ...�. ;' � n q o . � . with licensed cantractors ro construct the projed(Sec- - - �--- - -. ._..._..- -- �----- = ---�--- - �- - ' �..-'.-.- .� ' ' . ... ADDRE55 ` ` lion 7044,Business and Professions Code). • � � " �C�.(J : _REOUIRED - TOTALSETBACK �� � - - CONSTRUCTION LENDING AGENCY -� �" � - SEi eaCK v'4Ro- -� VROP.LINE wiDTii � � � � � - I hereby ailirm ihat there is o mnztruc�ion lending agency for FRONT , . ' � "���{1��r1 i)�'� �-the perfo.mance ot�ha wo.k tor whicb ihis pe�mi�is issued - -P,t. -- �-- � � ' -��- - -�� � ��- � � ---- - � � - -� -� � ... . _-- - � - �Set.3097,Civ.C.). SIDE �' i'('���.(j ' m Toronto Dominion Bank '`' - - Lender's Name 1��e LDMA Rei.M � � �- � 144 Sansone St., Sui te IOO . P.C.Fee E- ! Permil fee v-+�.Sa- . - lender's Address • } , . �. � � . I.tertify thm 1 have read Ihis applimflon and sfale thot the . ./5.��_. Issuonce Fee �j���-- �LOhV1 P/C M - � . - < obove information is correct.I agree io comply wiih oll Caunty invesiigaiim Fea �, ' . �g _ordinen[es and Stata I ws rel ting to b ilding mnsiruction, Toml Fea - ��Yy---���� -IDMA Perm.�M � � - � � � , � u ond hereby ao o ize prese �otiv this County ro en�er � - . - -. . �,a, upon t e ob • enf ned o rt f inspection purpose �s.� , � , . , � � _ . � _.__ . . .. ._. ... . ._ .-- -- ---- � -- -.. . __ � .. . . _-- . . a � SEEREVERSEFOREXPLANATORYLANGUAGE •. 1 ' o " ' � ' o ol p 'ont o. genr .... 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