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HomeMy WebLinkAbout0844A 0845A . .� .:�� . � . � . .'�."':. _...�._.�_,... ..` . ` � � WORKERS'_COMPENSATION DECLARATION � .... .. -.-;: _'-• '-_ . ..... . ..,,-". ....J..__ .,_... ._.,_.:.--_-'-- - _.'_-'. -'.'+ �a .. .. ,. .,. ,: .-'� .._ .w..L_.�..._. _ : �..-� . . . .- . - '� .. . ! •I hereby oNirm ihat I hove a certifcote.of�o�,e�,.,o,e�f -App��CATION� FQR:�BUILDING PERMIT �' . insure;or a certifimte of Workers'Compensation Insurance, or a certi(ied copy thereof(Sec.3800�Lob)C.)� �' ' ' � � �- - � � �OUNTY OF LOS ANGELES : � , �' BUILDING�AND SAFETY �����- � roi�� No.61WETX79q�am ,, � v aa�yNartford Groun - -.- __ .._ -- . . ., � _ . _ ._ _ - - - � Certified'co 'is hereb fumished.''� � '���-�� • qD RE55 � � /h0.w� Q'' PY Y FOR APPLICANT TO FILL IN � Cerli6ed�copy is f fed wi�h�lhe coomy bufld ng indpec- �� gUiLoiNG �� i � -"tion deportmenL �� . � - ADDRESS ], .. , ,... . . . , ' `..�r. .�:. �.-. ,� ", • ..._ . .__ __' _ ._.... ._ ..._.... � _ .. .. _ � : Date --�-Z�-�6�Applicanl�� l/ CitV Diamond Bar ZiP � LOCALITY 1 - � i � �. .CERTIFICATEOFEXEMPTION FROM WORKERS• ,'•- �. . . --"--��---- ' -'--- �NO.OFBLOGS.-' '-' �.. NEAREST_____.._""_" ' . _ ._.''"_'_'..____ _..._.._.. �- '• -' COMPENSATION INSURANCE�-������ -�>- SrzE OF t0T i NOW ON LOi - ' CROSS ST. _ . :. _,. � J . ` '.. . . ..._._ ASSESSOR. . .. (This'setlion need not be tompleted if the pe�mit is for one ... . . ........ _-.-. .-...'--�-----�.-- `,! .... . ......- . ._. _,... ., . .hundred doliars(5100)or less.)� A TRACT 425 J BLOCK LOT NO.80 µqp gppK'.� - � PAGE� PAR�L , .: � . �� . .. . . . . _- _. , TEL. p • . .__ .�_. . ... US �(E �+P I certify thot in t6e performance of the work�fo�which�this �NER� " NO - �yJ� �,p ! f= f .�3 � ��} permi�is issued,I shall no�employ any pe�son in any mcnner ' ' -�� �--- SPECiAI ----- -� - . � �� - -- �n. � AooREss - 3151.Airway-Ave. Su�te.N_-.._.__. - so as to 6eEome sObjecl tolhe Workers Compens6tion Laws. � Lb CONOITIONS Q oa�eice ro nr AaPi��o�,�,. • ... _ ._. nrr....Costa.Mesa _CA----z�r_:92626 __ _� - - - ---...-- -._._ _. - .__. � PLICANT: If, offer moking tFis Certificale of ARCHITECT OR " , TFL. DISTRIC7 GROUP• NPE FIRE., . �ROCESSED BY. �� I ' 1jnplion,��.you�5hould�becoma subjed�-lo-��1he�Workers' -� � � ENGMEER NO. - � ��1'7� CONS� ZONE ��V COmpensorion provisions of the Labor Code;you mvsl forth- ADDRESS 3990 Westerl Pl ace, SU1 tE.' L7Q � -..-/a--- /`J � d with comply wi�h soch provisians or.��his permil sholl be' ---� . . � ' ' 7E�, STATISTICA��1A5$IFICATION APT. ONDO. . � daemea�e�aked. ,:,, . „ . . .. .. . coMRAcroeBramalea Calif. No.850-1001 ; '? UCENSEDCONTRACTORSDECLARAT�ON.-�•. �' ----� � � -�--. . ......... ...___. _._ _ i�r _ . .__ '-ciq35No. oiv¢il.uNiiS � � � � � � � �"�_ I hereby offirm thar I am licensed under provisions of Chapter 9 aDORE55 3151 Ai rwa Ave. N No.409610 . (commencing with Section 7000)of Divaion 3 of the Business ond -"_.. _._......-_-.-_' .._..__. . . ❑C.'- ----. . ... SEWER MAP � �� .� :�, . � ----- Professions Code,and my license is in full force and�efiect. Cltt CLA55 B � ---�-��-�---�•�-�-'-� ��-` VAUDATION �- -�� ., . ,.. . � . . .� ;. . :� SQ.F7: NO.OF NO.OF CHECK � . . .. . 8K. pG. ticense Number 409610 tic,Ctass B''''' SIZE � STORIES FAMILIES � ONE � �� - . � . . . , . .. .,... _ . _.VAWA N � ;�,� ��. ... co�i�a�io:Bramalea Ca�lf Dofe •. - DESCRI IONOF�,oK--22AR-•:`----- --- N�+-. � . .. , -.'Q€�:;4"A � ,.. . s ���o�_...,. _; ' � � � � . . . ADD � ❑I om ezempl under Sea --�- �S1 fl 1 e.Fami 1 .Res i dence.___.._._._ ____..0 ;-- - ---t-.. + i-s-`2� --��� � - ALTER . - �� : s.sP.c.ra;rh�3«a5o� �. � New Constructi on REPAIR_� s__ . __._'_1..._. ._'. _ ........ _.'..r?uq.[,�'^.--; -- -' ..... ._ . _. . .. .. _._ .____ .Daf f_. • � USE OF � , ' , . E%ISTING 9lDG. �EMOL Q ' . ., u � ( )_' . .� q� .._.-. APP�ICANT TEL v^ � _5�o�e�.R � _ ._ IBl' bb N0S5O-ZOO1 DATE` � � PRINT OWNER-BUILDER DECLARATION�- • _.. ._�.�3 v� . .... .__a. . . - . PO(essonsCodea"amezemplfromlheContracror'zLicense - �� Rp�N� 31CJ1 A1T'Wd AV2. N Costa MBSd ' B ��•c.8 �i C� � low for the following reason(Section 7031.5,Business and fINAL ' `� '�`� � �... � . �... ___ BUILDING. . . .Y. ..�_ - `__ ' . . � . ., -. . I,os owner of�he property, or my employees wi�h ADDRESS � i� ' - �� ,� woges as fheir sole compensation,will do Ifie work and� LOCALITY ' �`� � ��A, ihe slruclure is not inlended or offered far sale�Section , ' r'�s. l .. .. __.___'__.'__ .". .. '__..___. . . _. 7044;BusinessandProfessionsCode): -�---� - - � MOViNG---- -�--�-� � TEt:-�� - � � - - . � � . I,as owner of 1he property,am extlosively coniracting GONTRACTOR NO. � ' � � ���� � � ' �.�._�! ❑.- wiih�llcensed conrracrors to consirocf the projecf(Sec- .. . . .-._.. ___ _ _...__-. _.. -_------...__......_.__. : ..----_ . ___. . .. _. . ._ . . .. � , tian 7044,Business and Professions Code). ADORESS . � � � a��1 s�Jc� ,; . ..... .._ .. RE�UIRED . i0iAL5E78ACKFROM I . •'��. ,:.� -' �-.:_`.!-'n' "CONSTRUCTION LENDING AGENCY - --� --- '�' �SET BnCK YARD' HWY' ""' pROP.LWE WIDTH � � ��- � � ' ������� -a�I�G..r)l� I hereby affirm�hat thera is a constrodion lending agency(or FRONi ' � �.'�-� ! '� • ., ; IhB performance of Ihe work for which this permif is issued -'-- '-�- --P.Lr_.---� -..-.- -----� '-'------'---- �' �---" ��''-..... ....... . .:�- - -'-- - '-p�'-�-0.-.�'6,--; ($e[.3097,Civ.C.J. SIDE ' .. . _ Tronto Dominion Bank. . _ - P` � ` � --_..:.` ___ ._.-:_-___ _ . . ---.. --..... , ..,.. � lender's Name �� ����� ��� �� '�� ,(� /J �/ LDMA Ref.M .-.'�','' ' ,,: . . . __._ ansome t. U1 e _.-' P.CfeeS �V'2'03--' PermdFee --T7`t•� ' _.._ '_. Lender'sAdd�esS�It��FP�llcle[O� CA 94704 .p c� � - , ,. - I certlfy that.l have read ihis opplimtion ond s�ate thot the . . . . d`.tS� ...lS'��- �- issuooceFro ---�d-'J�--�� �on+q riCN----.-..._ � ,:'�`� �' ' .' -"���� '-'- - -- --- - - obove tnformation is corrett.i agrea to comply wilh all CouMy investigatian Fee �/ � � ' o�dinances and Stote laws relating 10 6uilding conslruclion, __. -._.�To�ol Fee- -�7-��--��� �LDMA Perm.A�- ' - - - , . ,..., . . _.... . __ . ..__ . ..._ . ._ _._. ' ____ _ _. __..: � and hereby aulhorize representatives of ihis Caunly to enter upon the obove-mentioned prop ty f inspection porposes. y�� � ��� _. � .i'-;?,�. _ , �� � . . .._------ -� - �- -- ---- .'.-_-�----...... --___----------"O�. . ..- - -' '--- � � f� � SEEREVERSFfORE%PLANATORYLANGUAGF � . .. SignatoroofApplicontwAgeni . . . .__......pp1e._ . -' .____- . ._. .._.___..___...'__'__ _....__.._. _ .__. .:'_ ."'. 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