HomeMy WebLinkAbout1142A 1143A (5) WORKERS'COMPENSATION DECLARATION REGENCY III �I
, I hereby affirm ihpt I have a cei�rflcot�e of consent to self APPLICATION FOR BUILDING PERMIT ��
insure,or o certifimte of Workers'Com ensation Insurance,
or o cerlified mpy ihereof(Sec.3800,Lob.C.)
y 61WB�75��� y Hartford GROUI' COUNTY AF LOS ANGELES BUIIDING AND SAFETY
Polic No. pan
� Cer�ified copy is hereby 4urnished. FOR APPLICANT TO FILL IN eui��wc�
nooRess �ffi 896 S. Le land Drive
rl�Eerlified copy is filed with ihe county building insper gUIL�ING
��� ��or,department. A�DRESS 896 S. Le land D iv
Dare. �� � APPl�caorttramalP:� n.��;f �iTr D.B. Hills iiP iocnurv n.B. Hills
CE IFICA E OF EXf_MPTION FROM WORKERS' NO.OF BLOGS. NEAREST
COMPENSATION INSURANCE 5rzE OF i0i NOw oN�oi _ CRO55 si.
(This section need not be mmpleled if the permit is for one ASSESSOR
hundred dollars(y1ppJ or less.) TRACT L{' ] BLOCK LOT NO. /�qP BpOK VAGE PARCEL
owrveR Bramalea Calif., Inc N�, 850-1001 ��p�NE NOP �/y.-- i��
I certify Ihat in the performance of the work for which this ��
permit is issued,I shall nol employ any parson in any monner qDDRE55 3151 Airwa �,V2 Suite N �r L� SPECIAL ��
so as to 6ecome su6jecl to the Workers'Compensation laws. , / CONDITIONS �
U
Date Applicant CITY ZIP �
ARCHITECT TE� DISTRIQ GROUP TV?E FIRf. PROCESSED BV CJ
NOTICE TG APPiiCANT: ff, o4fer making this Certificate o4 ENGINEER`�`�m Bc1S50ri18.R Np �Jr2-186�F C ZO�..� �^
Exemption, you shouid become subject to the Workers' — J/1 J� �,a \, � ,J �,.� �
Compenwtlon provisions of�he Labor Code,you must forth- q0oae55 399� WeStel'� P18CE �{'1�0 r�" �C r...3 y� dl1 ,�' �
wi�h comply wirh surh n.ev�s�ons or this pe�mit shail be •-- - ( Q-
deemed revoked. O�B TE�� STAi7S71CAL CIASSIFICATION APT. CON . [f)
CONTRAC70R NO. 7
LICENSED CONiRACTORS DECLARATION ���. CiA55 IJO. ��� DWELL.UNITS� �
I herehy afiirrt�tha�I am iicensed under provisions of Chapter 9 aooRE55 No. 409610
(cummzncing wilh SeUion 7000)af Diwsion 3 of the Business and �— — ��� -- SEWER MAP
Professio�s Code,and my licensa is in full forca and effed. CI7Y CLA55 B _ BK � YALIDATION
50.FT. . � � NO.OF NO.OF CHECK
License Number 409610 Lic Class B SI7.E STORIES PAMILIES ONE
-�_ (,,r�rJ� VALUATION
Z DESCRIPTION�OF WORK NEW }� 7, �.)
Contra[tor 0�B Date '�/� AUD � S /^�� y � 'G
❑I am exempt under Sec SrR ,
Plan ALTER � �5 i G.G F�
B.BP.C.for this reason �� __ � $ i , ,�:-
REPAIR �j � � 5
USE OF
Date: DEMOi
EXISTING BLIX"i. i W S.���-i``
APP�ICANT TEL '
Signature PINAL �„' �
akiHr�Brmalea Ca1iE. No 850-I001 .,�,�`�� m ,-,�� � .�
OWNER-BUILDER 6ECLARATION DATE � �
I hareby affirm�hat I om exempt from ihe Contracror's License 3151 Airway Ave N� �)OStd ME�$E1 �
Law for�he following reason(Section 7031.5, Businr,ss and A�DRE55 FINAL q �,-,.- ,c
Professions Code): PBE ENT By "�;t,r,,t,Ln�. L�,�`"--�`'
❑ BUIL�ING
I, as owner of the proper�y, or my employees wi�h ADDRE55
wages as their sole compe.nsation,will do the work and �OCALITY '
Ihe siructure is no��ntended or offeied for sale(Sec�ion �
70d4,8usines:and Professions Code). nnovmG TE�. � � �� q 4 ;�
� I,os owner uf the properfy,am exdusively contracting CONTRACTOR NO. ,. � '
wilh licensed confractors fo mnstruct}he projecl(Sec- qD�RESS � �T' ° s " ' " �
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY SET�BACK YARD HWV TOTApROP.AIMEFR WIDTH �� � ' � "h���[:C O
I hereby affirm ihiat�here is a canstruciion lending agency for FRONT ' �
the performance of the work for which ihis permit is issued P.L ' - " ' � � • e �;i�l�.�;:;1��
(Sec.3097,Civ.CJ SIDE A , ^c
1"oronto Dominion Bank P.i. . �j;;,,�;;_ �
Lender's Name ,� LDMA Ref.#
San Erancisco, Calif. p.C.Fee$ ��'�: J'S✓ Permitfee � �Q - �
Lender's Address ,
I certify ihat I have read thi;applicofion ond state ihat Ihe � �•C�.�� Issuance Fee 10.50 LDMA P/C#
above information is correct.I agree lo comply with all County inves�iga�ion Fee
ordinances and State laws relating lo building consiruction, Toral Fee ��� LDMA Perm.q
and hereby aulhorize represenfatives of ihis Coonty to enter �
upan ihe above-men/tion d properfy for in5pedion porposes. � , � � . ' ,.,
. �.2l=lc.r-e G��,d� � LDMA 3�fl o�.5"-v-
��[t SEE RE4ERSE FOR E%PLANATORY LANGUAGE '-
� Signoture of Appliconf or Aqent Date - � - '
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