HomeMy WebLinkAbout1140A 1141A . WORKERS'COMPENSATION DECLARATION RF.GENCY III �
. � he,�bY atf�,m ,ho, � �a��o cerfifimte of�o�se�,�o se,f qPPLICATION FO� BUILDIIV� PE�lif11T Li
insure,or a certifim�e of Workers'Compensation Insurance,
o.a ce�rf�ed copy�hereof(Sec 3800,�ab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
61WBMX75YOE Aartior d � Group
PolicyNo._ Company
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN 6uu��Nc
nooaess 890 5. Leyland Dirve
r�Certified copy is filed with the munty building inspec- BURDING
�J uo�deporlmenL ADDRE55 8 0 S. Le 1 nd i
'`� '" Bramalea Caiif. D.�. Hills D.B. Hills
Date J��_,Applicant ❑1Y ZIP IOCAtiry
CERTIFICATE OF EXEMPTION FROM WORKERS' No.oF atoc5. NEAREST
COMPENSATION INSURANCE SiZE OF�OT NOw ON LOi CROSS ST.
(This section need not 6e completed if�he permif i5 fpr one ASSESSOR
hundred dollars($100)or less.) TeAcr_._42578 BIOCK LOT N0. MAp BOOK PAGE PARCEL
OWNER B�amalea Calif., IncNo. 850-1001 u$ z e �+P �'/
I certify thal in the performance of the work for which ihis Y/�� NO. � e-�j� ,�
permif is issued,I shall not employ any person in any monner - �t��,�SPECIAL �y
5o as to become 5ubject to the Workers'Compensafion Laws. ADDRESS 3151 Airwa E1V2 Suite N CONDITIONS �
Costa iKesa 92626 cJ
Date ApplicaM— CIiY ZIP �
NOTICE TO APP!ICANT: !f, after making �his Certi£icpte of ARCHITECT OR TEL. DISTRICT I GROUP NPF. FIRE PROCESSED BY C_'}
ENGINEfR ' NU� CO ZONE U
Ezemption, you should become subjecs to the Workers' — /� �f�!
Compensafion provisions of the La60r Code,you must fprth- qDDRE55 399� Westerl�Place ��1�� I� /�."� 1i � �' L�
with mmply wifh such provisions or this permif shall be TEL STATIJTIIAI CLASJIhICHIIGN APT, CO DO. Vj
deemed revoked. CONiRAQOR NO. ��
LICENSED CONTRACTORS�ECLARATION ��" CLA55 NO.fi �_T�!DWELL UNITS�`
I hereby affirm tho!I om licensed under provisions of Chapter 9 ADDRESS No. 409610
�commencing with Section 7000)of Divlsion 3 of ihe Business and ��� B SEWER MAP
Professions Code,and my license is in full force ond effect. CiTv C�A55 BK � � VALIDATION
50.FT. - NO.OF NO.OF CHECK
License Num6er 4�9h 10 �ic.Class R SIZE -- ; STORIES FAMILIES ONE
VAIUATION
)_y Y � - D�SCRIPT!ON OF WORK NEW X.�e
Contracror � , Date_J_._2.�/ ADD ❑ s �� ���
�I am exempt under Sec SFR �,,� .
� ALTER � �: � I !F.'�F.
B.SP.C.{Of 1hi5 r8pEOf1_ P13I1 O �
REPAIR
Date: USE OF � d�e ° ° °��
EXISTING RI.OG. �EMOI
Si�nature� APPL:CANT 7EL. RINAL �,r j �(�- 1 ':�`;
vewnBramalea Calif. No. 850-1001 �,
OWNER-BUILDER DECLARATION pApE `7��� a °/�'� c r(� � �; :,,5�
I here6y affirm fhat i am exempt from the Contractor's License qDDRE55 1 1 E�1TWc7 E1VB N OOStB M25 ilMAR ��
Lav�for the following reason(Setlion 7031.5, Business and ,
Professions Code�� p E By _�-A�c����— U�:C%�"v C:
� I, qs owner of the ro ert or p Y RUILDING
p p y, my em lo ees with ADDRE55_�__._._..�_.___--___..�
wages as their sole compensation,will do ihe work and �OCALITY �
the sfrocture is not intended or offr.red for sale(Section .
7044,Businass and Professlons:ode). MOviNG TEL . . .
� I,os owner of the property,am exclusively contracting CONTRACTOR NO. , =�� � � �I ry'
with�itensed coniroc!ors to cons}rucf the project(Sec- ADDRE55 n � e e u -
tion 7D44,Business and Professions Code). " I
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH � � a`��`;�!���'�
i he!eb•;affirm th:�!there!s a construction lending ogency for FRONT i .� �
the performance of the work for which�his permit is issuad a.L. � a :.r�.„r
(Sec.3097,Civ.C.). SI�E . '�' /�'•J J�`,"
Lender's Name
TORONTO Dominion Bank� �� G�e,`�-8 S
,J "� LDMA Re£.p � .•. , �
Lender'sAddress San rrancisco, Ca1if.
P.G Fee$ 7✓-���� Permii Fee %�-y (J '� '
I certify that I have read ihis applica�ion and swte thar rhe �•�"��'Q�U�° iss�a�ce Feel�•$� LDMA P/C R
_ above informotion is correct.I agree te mmply with all Couny Investigar�an Fee �
ordinances and State laws relating ro building constr�ction, To�al Fee ����C, LDMA Perm.#
and hereby ouiho�ire�epresentatives of this County to enter .
~ i�pon ihe abave-mentioned properfy fo;inspecfion purposas. . .
��/ �,�.(r�
� /J� �+�, ��CJG�'Jd`jU `�fI- SEE REVERSE FOR E%PIANAl O Y LA/�NG�VAGE . _ ,
• Signa�ure of Applicant or Agenl Daie � '
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