HomeMy WebLinkAbout0651A 0652A WORKERS'COMPENSATION DECL4RATION � � ��
I here6y affirm thal I hova a certificale of consent�o self APPLICATION FOR BUILDING PERMIT �
insure;or a te�tificate ot Worken'Compensation Insurance, �� � �
or a certified copythereot(Sec.3800,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poi;�YNo.fi1WBRK44Q�m�„Y Hartford Group
Certified co ��ii lieieb furnished. BuiLmNG �q
❑ PY� Y FOR APPLICANT TO FIIL IN nooaess ��/1 ht¢.�.J— d+'.i�
� Certii(ed copy is(iled wi�h�he county building inspec- BURDiNG
.tio.de rtment. ADDRE551311 S. �Lon view Drive tOG4LITY �•�
NEAREST,
Do1e ApplicoN CIN � ({ ZIP CROAST. . �
� - ,C TIFI ATE OF EXEMMIDN FROM WORKERS' NO.OF BtDGS. ASSESSOR
COMPENSATION INSIJRANCE SIZE OF lOT NOW ON LOT . MAP BOpK PAGE PARCEL
(This secfion need not be completed if tha permit is for on ZONE tiv+P � //'_ �
hvndred dallors(51001 or less.) TRACT 42558 BIOCK �or r,o. 53 �p, No.
OWNER � NO. .[.(lOVO CONDITIONS S
I-certify that in fhe performance of 1he work for which this piSTRICI GROUP TYPE FIRE PROCESSED BY 0
. permif is issued,I sholl nol employ any person In any manner AooRess 3151 Ai rway Ave.� Su i te N . coQ,s:. Z.l�y� � U
so as to become subject to the Workers'Compensa�ion Laws. /J p`3 ' �
Date Applicanf - � Gltt C��ta Mesa,-CA ZIP 7Z6Z6 S�ATISTICAlQA551FICATION� APT. CO DO. F�
�TICE TO APPIICANT: If, after making ihis Certifitate of ARCHITECT OR TEt. _ �
emption, you should 6ecome sub�ect to rhe Workers' ENGINEER Ar m NO. QA55 NO. �� OWEIL UNITS� �
CompensatiOn provi5ions o{iha La6or Code,yau musf forlh- pDDRE55 3990 Westerly P1 ace, SU1 t2 170 SEWER MAP �
with comply with such provisions or this permil shall be TE�
deemedrevoked. . � COMRAGTOR Bramalea Calif. No.850-1001 �
BK. p�, � VALIDATION
UCENSED CONTRACTORS DECIARATION uC. �
I hereby affirm that I am licensed under provisions o(Chapler 9 ADDRESS NO. VALUATION
(commencing with Setlion 7000)of Division 3 of tha Busineu and COStd Mesa �{� ���' �
Profestions Code,and my license is in full force and effec�. CITY s Rq55 5 �p Q a -��b�� A �
409610 B s'ze�'1430 s"roR°s 1 Fn°rni°is 1 o�K , #• • • �2 1
LlcansaNvmber Lie.Closs
c,�„o�,,, Bramalea Cdl l f.pa�B 6-5-85 DESCRIPTION OF WORK ^� � s I •2 5 2 5 S
Stucco Dwellin A�� � .�� _
�I am exempt vnder Sec. 9 ALTER � FINAL 2 5 2 5 8 c�� ,
B.BP.C.for this reason � S1 fl 1 e Fami 1 Res i dence - REP;,,R � DATE ��o���- . � 0 6 1 3-8 5 �
USE OF
� Date: EXISTINGBLDG. DFMOL � e1NAL Q� � . . .
Y �d'��
Signoture AP�pR1 TT Bramalea Calif. In�;o,850-1001 - �
OWNER•BUIIDER OECLARATION. . �
I hereby affirm lhaf I am exempt from the Conlracfor's Li nse ADDRE55 3151 Ai rwa AV2 COStd Mesa CA � �0 6 S 2 A
Law for the foliawing reason(Section 7031.5,Busines and � � {� .
-ProIe33ion5CodBJ: � PRE ENT ti��:���'• • � '
. ��� � BUILDING . . . . . .
I, as owner of tha properfy, or my employees with aD�RESS � •4 3 5�0 0
. wages as their sole compensatton,will do the work and .
� tha slrotture is nat imended or offered for sole(Section ����TY - i •'�4 3 5 0 0 c=.o -
704d,Business and Professions Code). MOViNG TEI. 1, . .
� I,as ownet of the property,am ezduslvely contratting NTRAROR � - �• - � ' � ',I ' O Q� �J�8 S
wilh li[ensed confracfors to construct Ihe projact(Sec- ppDRE55 ' � �
tion 70<4,Business and Professions CodeJ. , .., � � � �
REQUIRE� TOTAL SETBACK FROM Ex15L �
� CONSTRUCTION LENDING AGENCY � SET BACK YARD HWY PROP.LINE WIDTM , � �^�
I hereby affirm}hol there is a mnstrutlion lending agency for FRONi � � ' - � � � . .
the performanca of the work for which this permit is Iss�ed V.L.
t5et.3097,Civ.C.)• SI�E . ... . . . , �
Toronto Dominion Bank � P•`• �
Lender's Neme Q '
114 Sansome St. Ste.���� P,�,FeeE �S..C.S!3 PermitFee .Z •� v + t� f
Lender'sAddress ___:___ rn nn�nn . � �
.ian �� . �
I ce.tify Ihot I have reod this opplicotfon�and state that the i:suooce Pee �d `s� � �
above informo�ion is corcect.I ogree fo comply wi�h oll Counry mvesi�gor�on fee � . . �
ordinances and S�a�e lows reloting lo b�ilding conslru[ffon, � To�al Fea 3s' '�Q � '
and hereby authorize representa�ives of this County to enter ,
vpon ihe above-mentioned property far inspectio pur oses. � ; �Q�J� /O� � .�o� __ R
•7 d`8'�J
SEE REYE E FOR E%PLANATORY LANGUAGE�
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