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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� Signa�ure of Applicon�or AgeN pere - . . . mt rn-r� ()= r m t+ f/i T � N :n� � � i+ = t ' �1 � �' o o ° ° � n o ° �o 0 0� nv � m � -n - -o -- -- - - -; o` o o'o c s T � 3 0., �,. �o �' •o� o n_ n � o Q "�.' 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