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HomeMy WebLinkAbout0848A 0849A .,.. ,. . . .,., „.,,,. . ,., . .. ...._._.._------ -�--�-----._ __ _._.._.__.. ._ _ _.____._... ._._ , WORKERS'COMPENSATION DECLARATION ��..' . � �"•; �� ^.,~:� �~�,�;' •: :7 � � . ..-.. ,, . . . � .I hereby oifirm that_I�have a certificaie of consent�ro self � ���� � APPLICATION -FOR BUILDING-�PERMIT ��- -� , insuie,or a certificole of Worke�s'Compensation Insurance, '-.. . . . .- --- -� . , oraceriifiedcopythereof-(Sec.3B00.1o6.'C.)���..'. .. ... ...... .. .. .. . '- - . . --... . --- � COUNTY O jLOS ANGELES , BUILDING;AND SAFETY =,.:. � ��' ,. . . . ' _ .. ,. __ _ _� O�,.N�IWETX7993com��Y. Hartford 6rouo . eun�ir,c ' ,Cer�ified'copy�s hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 d � . Certified copy is(iled�with the covnty building inspea ' � BURDiNG \' ; I �tion departmeM." �• '�' ADDRE55 lO SO h Lb V' �(' ...-. .� ,,. , � _ ` � ooi�_�Z�-�cPaira�,- a,r ' m nd B zir �ocnurv , ..� .��„CERTIFICATE OFEXEMPTION FROM YJORKERS•.,. _.. . .. - '"--'-.`..'. -. NO:OF BLDGS:---'�---' -' NEAREST ---.'.- -. ..__._ . . _____"'___'.'_-"' -'_- � �� � � ����COMPENSATION INSURANCE�����'� - � � SIZE OF LOT i NOw ON lOT CROSS ST. ' . .. . �...... � .. /' ASSESSOR , . .. . . .__.: ., . _ i (Thfs secfion need nof be completed if the pe�mit�5 fa.o�e ------ TR,;n����4256 �BIOCK lOT NO. HZ�/ MqP BOOK ��' � �'" � PAGE� PARCEL �� hund�ed dollars(E100)or less� .:. _ ... - � TEt '�- ��',. ,�, � '. . ...._ . .• • '._'"" ' .. AMP I certify thbt in�ihe�performarice of 16e wo�k for which�this OwNER No - � ���E p�p ,l��� f/ �• '} I permit is issued,t shall not empioy ony person in any manner . . �� --. SPEc1At- ....-._.. .. . . ..- -^ �-- -. .. .a .. so os to become subjed�o�he Workers'Compensarion Laws. � � ADoaE55 ]. - 1 W V2 r'$U l t2 N- -� --�--� � O V Dale ' �'' � '���Appl¢aut � .� ` �. • . 1 "�--.. C�iY_..COStd Mesa,. CA....."'ZIP._JZGZE._._.. . .� -. . . CONDITIONS" ... - ' '.,.-n..' _-"'� , '�TICE TO APPLICANT: If ofter;making this CerhLcole of ARCHITECi O 1��• DISTRICT. GROUP NPE. . _.__ FIRE _PROCESSED BY� ,�� I ��ption,��yoo shovld betome 3ubject to�the-��Workers' - ENGirrEER T1ram Basseni an No.752-1864 `- m � Z� - W �ompensalion provisions of the Lobor Code,•you musf forfh- ADDRE55 � l.� ��. _- __ _ '.. ___- G. with comply.with such provisions or this permil shall be ._- -�� � � � ��� ��n deemed revoked.,. - � . TE� STATISTICAL QASSIFICATION APT. CONDO. 'Z . '', '�. � '"�4 �� -�� CONTRACfOR Bramalea Calif. No.850-1001 � � - • _ ... — LICENSEDCONTRACTORSDECLARATION� � �;� -� -� --�-���- - ��� -- �-; -��- � � ���-�� - �- �-�--�- � CLnSSNO.��WELL.UNITS ltC.- 1 hereby affirm thot I om licensed under provisions of Chopter 9 ADDRE55 3151 A�rwa AV2. N No.4096�10 (commencing wilh Section 7000j of Division 3 of the Business and ._ LiC. -� �R�P � � - - � � . . ........._-. -. ."_ _._..._ .. . . � Professions Code,ond my I censa is in full force and effeU. Cltt C1n55 B �` ���- -�� �� " VALIDATION�' � � .. . ... ..... :. � �. � . . . . ... � ,r.� �. SQ NO.OF NO.OF CHECK_. BK. PG. t � _; License Nvmber 409610-� � ��• � �;�.eia55 B �� ' � � - SIZE� 4Z� STORIES-�L FAMILIES-1 - ONE � � - ��':�•': - - � � ' , oesea��ori woaK 25AR ,L _ � New--� _v t _ _ . . ;_ --�0&G.8 A . . . . _ .. A UATION ,_. coouo��8ram�laa rd�lf. Dafe ` _ ADD � S �3S �DO ' �;� . . .21 . . . . ❑I am a.empr under Sec. - . ---$l f19�2.Fdflll�y_R2S1 d211C2_.___ _ ___ , ,... .. ALTER . . . : , , . . .. ._. ... � e.aa.c.ro.rh�:�eeso� __ New Construction REPAIR ❑ ._s .._.._. .. . _ _-----_ .�..•3.��._�.Q ; _._.. .._ -. . -.. .,. .."__.'__'DateC- ._.' USEOF DFN10L � ! n o J R L� Q�_' ExISTING BLDG. fl ne � -� ���-�-���-��� - - .,.. ' '�� APMICANT TEL. - �s'9"°'°'e A-��� � PRINT Bl'uce L. No.850-1001 � FINAL v ���, 9� 9 8 6 O NER-BUIlOER OECLARATIO �-DATE--��� --�+•-�- �--- ---�- - ��I hereby affirm Ihat�am exempt from tha Coniratfor's Licensa 31�j 1 A71'Wa Ave. N Costa M2Sd � Law for�he following�reoson(Seclion 7031.5, Business and /+DDRESS y FINAL`���' � ' � � � ....__.__._. _. _ .. ._ .. . _._ . _._ . ... .... ... . ..P�ofessions Code):.'. . .-_..,.._ _..,.-. . .._ _ R N BY� . . � 6UILDING . �� � - I, as owner of the property, or my employees with ADD2E55 � � '_J woges ai theii sole tomperisalion,will do the work�and ���� � � � � � � � � � � ;U O 4 Y A � ' the sMutture is not inlended or ofiered fo�sale(SeUion ��`��TY , r''� � ":-`, ' ' ' �i . ... 7044.Bvsiness and Professions Code)..._......� .. .....- MOViNG . ...... . ..�_.... . .--�-� - �� tEL.--. ... .- .... . . . . -...% : _ . ' ' . .. . . e-e � �,as owner of tha properfy,am exclusively contracting CONTRACTOR NO. � '� : ' � � � with licensed conrroctors to construcYthe project(Sec- . .---� aDDRe55 -.. ._....---. ---......-. .._....._._ ..._... - . .-- -.... — .--. . . .� e 6 5 t;0�0 - - lion 7044,Business ond Professions Code). � �� ��• .RE�UIRED_ TOiALSETBACKFR '� �'\ \ '� �-CONSTRUCTION LENDING�AGENCY -� � -�" � SET eACK YARD� -NY✓Y � PROP.LINE wiOTH � � � � -" "J���•O O c' �. 1 hereby affirm lhat there is a construction lending agenry for fRONi � �.�� - �� ' � � � ' � __.-'. -the per(ormance of the work for which this permil is issoed ---..- ..r.�.�----.- ...... ._....._. __...,--- ----......_._._.._ . ..-- � -.-���t :�-'...� _ .._. ..:. ':: ...'.---. .0�j� Q-$.(� .. (Sea 3097.Civ.C.). - SipE ..i '. . - __... . .. . '_'._.. .... P.L . . �. ' ' ' ..._. � __ Lender'sNameToronto Dominion Bank ,'(� ' � � j .'_ . ____._.14Q �dnsomg.St... � �. P.C.Fea E....�9 • � _._. Permrt Fea _-_�y �.� - LDMA Re1.N ':._;• •.'."t �� . . -. �-I _.._' _ _. lender's Address$.a(�� ���-: �� - � . 1 .� �_ '. �. ��. c ..�•:_ � . . . .. .-.. _I eert'rfy that I he�e read th�s opplication ond st6te tFat.the --.--_ L•dMJ• _.�5�!?�-- hwo��e F��----.-/Q.-`��-.; -LDMA P/G M---.. . .- .. .-- ---:. . � ._ . .:...': obova informotion is torrecl.I a9ree to comply with all Covmy Inves�iga��on Fee '' ._ordinantes and Sta�e laws relating,to building construction, .._. f �.___' � � '� -' ' .'.. _'__...._ .... Total Fee_""' .�-/- ' LDMA�Perm:M_'... �...__.... ,. .. ...; _...._ .._....__.._.... .""__'_' _ "'._'." . ..._.. ... .._� and hereby authorize representatives of this Counry to enler , upan the above-menlioned prop ry or inspettion porposes. y � _ ' ._ _ . _.. ..___' " __ ._ _ __ _ __. _ ._._ " _ ._ .. . .__ _ ' ._. __....._ .._p� � ""__'.' __� .. _ ' _ ._ ..__._. . .. �� . SEE REVERSE FOR E%PLANATORY IAN�AGE T �� . ........__. � .i• .�� _... . _Signarore of App icon�or Agent .. .. ..� Date_, . . _;... . .... . _.._ ._. . '."_ .. ...... . . . .._.. _ _ . ' " .. '' ' ' '�' . � Q . ,-. _. .i �' � � o .o ' ''�- �� �,� ' .` `` �. • Ct �.. � p ,i �'v 'W c O ? '!'� Y O �-u' . �o. % 5 �mp a � '6' t0 O � \w�;. ..9. ,�` ID .Q � % j�, m�% �^ O n ,e'. - �0 `' . ; O. �J7"�'7 �O�O � o ,? m /� + `` .. ,'. '1 "a'. � N� . � p Y)��.: O p � . �`• ?' � '.. _ .� O . � � p � a �� b � �o�. �n .._ � ��\ 1 �, � � � r O t� � � x � p • .{i� % ;� . � 0 7y•• A m� �� 7 7 Q � � a d r � �� � .[ - �C f1 � t�� t9 N i*� N.L ,�i, O v1 p- ' . , �in � r• �.. +� •O Z � y� w� � p � O 4 � 9 O � y �t .t �' ^ 0 3� o \ � � . , � a. � . c c-, 1� � =� , o . � f �..\ � N c�� y ° ,� � . .; � � . , . ,y .., ��� e( . M o ,� tv � N � `,C !� ,• . .. o � -ri, CS� c n M C ' n , � , 9�p c l c n J � ;` . � " '��+ o. 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