HomeMy WebLinkAbout0954A 0955A (5) , , _._ _ ._._ . _ __ .. . .... _
__ _ _ _ ... ..
_ _. ___-- .-
-
' . 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 .... Da�e.. ... _.._ . . ._.. . .. . _. . ._ . ��.... _ _. ._. � .. _ � .. ..'__ . OO i
I
z a
o .
�T' � O
'�' '� Q �
cr �o. a� °' m a � 4 0
� C�'o � ro o � v cc -, ,o 0
-o 0 0 � � ; ,o. �o o .fl �..
0 0 � �"o �' . " o 0 0 ,c
F � o 0 3 a
� a p � o ro 3 m � '^ p
U+ O N� � O Q-ND �� p O ^ N
� o � 6; ? � '^ � 'o'� ..�
r � �(D� 3 � O F� � �O ��O � O O
= O S N � O �� 7 �
'j Q� ? j d � a .0 A ��L ' A r
�5; (�� N l0 fn A^C N N � ~ i 1 'p ^ n
'�� ��� o �� ^., Z � 0 4 c a a M m � F
?� � fi°c `�. % o -' � 9� d A 2
..� � v 3 0 �� o C�,'^L. `o� ' ► o' ..�
� ° �� ° � a �
; a; \ Z
� ^ o � o
� �
� N �
� c� 4 C� - O T
o c , o � v
41 • <ir � a �o
1 1 � � J - 9 • �
� d
0 0
c
M �C
m b� .
l ,�. �
O
� � � M
r
( 7
� pt � �
G
O' ,
� � � � �� Z
q
f�
. �
7�n.
�i, . ' �
• �
. � ' - N
,rt G C. .�
. ' , ,�, � ..c. �' � c�i
N. �
^� 9 p O C n �^ U"��O' '� r � Q
. � e%.,�� "� �`' o `""'�«.v� '�^ r'� `
' •• ��"^'� O �'�p p� �� �. .�.P � � O 1
�•2 �? � y.� Y.N�7....v'.,��,,,,o O p r^�,,,��o c'� '<.
� _ c -- ��. t- ^'� �~ : 0 3 x
a-r.o' " �,-���x n�'� �� o ��=.»•°�, -o c::� s G
� �%� e � j£�K s`..y�V� �� m � o �..� ��'S..c..� A � �. c�a�:�
, . o o Q ���� =T-o c b n �� � =��� o o� � � � y o� c �.=' N N o 3�
� � p NF �•� �: � 4 'C'�R� � �` i� 30� c ae�"'ns�` �� � `� � C
3 �-s t...« � � �,� o�.� �� � �co 's o r o,,,-c � t
� X ^•C r � 3 a pw n� 'c ^ .:��� P '�" (40 b(9"D `-•�C c o C..i° O ^�O _�� 'D r
ro � „ Nas--� ` �-- o � `r._s no.� o ra'�.� `° �� " fik m -^,"�'
�
3 s o ...3 � "'' � - � '^ m �,� c'`;,'�r ��v- ;;H'' _, o
' �. � ��3=.,�� 1O c= c.�c� `-'• o o ;c K � � � �'O o N� �v o3Y�
� �._� ^"� " o o �-�� c.' r--� -��� c..L-•=.,o ;, � x? °, � ,.
y ry K.S� �..i^•N� C-� c "J�N ' o � �c � � �' t^� N n =-�� ° ^ u+ 0
u• �-y_ a _ � " q, � `^ a_ �,.G � c.. � � ^ � - co n 2
- '� ry v G � a �=L o a�:. ^ ' �=a c �..3c 5..4^_C� .^,.M F.v� h « n 7
' - � - n ....�x �7 p . O''�'.��-ti.+.���' .. u,,p (D .r� 3 Q'b JC��-w„' ;,`Q V ..{�
�
O e� � ° t..� � �.�� � c"� -�,. s. o Sv N ^-..rE, o F =:.i � F Ow^-.
�p ,y �� � � ry „1 �i'� ea � � fj p N��.� = �C O
N ie C • �
.. L. y ►:� � O � � �..�C„�� 'C'�N��tD v�C �C M,ynm ' �L'��n
. c� Q .y �`��u�. �..^..� �-a �.� ,-.� �.y, `^V�y O �� ..
� ' � � ��„ �� Cl� i "� t'^C, n �"i. d'����p �. ��.•� �' ~ '
'� � t. n � ^ O -c � .�- �,�L'� � N a 7 ? ' _
Qp ..n 3 �p r ~t�...- �O-
. y 'd 7,...,y `t n c: r C Y .. � . .
^ � O
D � � � "
. Cl -a+L N `•� io ."-
o a x. ^� cD p. =• .
O .. � ...� n �
S ' � ..�O
N