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HomeMy WebLinkAbout0661A 0662A (4) WORKERS'COMPENSATION DECLARATION � � I hereby affirm that I hova a ce.�ificote o(�a�,e��,o self APPLICATION FOR BUILDING PERMIT � insure;or a certiiicate of Workers'Compensalion Ins�rante, or a certified mpy thereof(Sec.3800,lob.C.1 COUNTY OF LOS ANGELES - � - BUQ�ING AND SAFETY PolicyNoF1WRRKdq$qCompany Hgrtfnrri f;rniT BUttDiNG � rtified copy is hereby turnished. . FOR APPLICANT TO FILL IN ADDRE55 �.3-/ . o�ti• Certified copy is(iled with Ihe to�nty building inspec- gUiIDING r n eportmenL ADDRE55131 •S. Lon vieV� DriVe ��un' �•�� Diamond Bar NEAResr Da�e �pplitanl CIN 21P CROS55T. ' �. C RTI ICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR � COMPENSAiION INSURANCE � SIZE OP lOT NOw ON LOT Mav BOOK PAGE PARCEL (This section need not be completed if Ihe permit is for on u5E ON hv.P //� 3`� hundred dollars(E100)ar less.) . TRACT BIOCK LOT NO. ��/� NO. Y• iEL. ' SPECIAI Y� OWNER Bramalea Limited No.850-1001 �Zoopv coNoiTioNs � a I certify that In the performance of the work for whlch�his DiSTRiCT GROUP TYPE FiRE PROCESSED BY � permit is issued,I shall not amploy any penon In any manner pDDRE55 31rJ 1 A1 T'W3 AVe Su i te N CONST. ZO � V — so as to hetoma subjecl to the Workers'Compensation Laws. /v �_3 _ . y, ! Dafe � Applicant . CITY ZIP STAi15TICALQASSIFlG4TION . APT. CONDO. O ARCHITECT O TEt. /,..,) (J � �OTICE TO APPIICANT: If, after making this Certificata of ENGINEER `�ram Bassenian No752-1864 QASSNO. UV OWEIL.UNRS� W kmption, you should become subjecf to the Workers' . a Compensotion provisions of fhe Lobar Code,Ya�m�s�ro�,h- nooaess 3990 Westerl Pl ace 5ui te 1�� SEwER MaP � with tomply wifh suth provisions or �his parmi� shall be ? deemed revoked. . � '` TEt. � BK � VAIIDATION CONTRAROR NO. LICENSED CONTRACTORS DECLARATION ��c. �p 6 6.1 A I hereby aiiirm thet I am licensed under provisions of Chapter 9 noDRE55 3151 Ai rway Ave. No,409610 VALUATION � (cnmmencirg with Section 7000)of Division 3 of the 9usiness and ���" � `/ �O O tR• • • •2 1 Professions Coda,and my license is in full(orce and effetf. CIT�COSta M25 d CA 92626 GLA55 S �T � � SQ.Ff. � NO.OF NO.OF CHECK titense NumberaOQ6�O LiC.Class B SIZE STORIES FAMILIES ONE - � � •3 4 2 eonfrac+or Rramal Pa f.al i f_ oa�a �/�/R�l DESCR�F�ION OF WORKr�an 24CR Nex � S 3 4 3.6 2� ❑I cm exempt under See. $1 fl 1 e Fami 1 Res i dence ADD � 0�� 3`8 5 ALTFR o F�NA� _ _ � B.BP.C.for this reason� � REPAiR � DATE j /O/�G � Date: u5E OF . FINAL EXISTING BLDG. r1OIlE DEMOI ❑ B Signatura AP�pQjNTT No. — 1 y �0 6 6 2 A OWNER-BUIIDER OECLARATION , 1 hereby affirm that I am exempt irom the Contrattor's lit se �t• . •.• • � Law far the following�eoson(Sedion 7031.5,8 e on ADDRE55 � . Professions Code): . . . � PUESENT I •5 8 8 0 0 � ' ' ' BUILDING ' � I, ae owner of fhe properfy, or my employees wilh ADORE55 •5��O O U, - wagesastheirsolecompensation,willdotheworkond . , the structure is not in�ended or offered for sale�Sec�ion � ��`��T� � 7044,Bvsiness and Professions Code). MOVMG TEI. : � � � � .. O C�� S—8 Jr � I,as awner of the property,am excl�sively contracting . f MRACTOR NO. ��r . � ,. � with licensed contractors to consfruct the project(Sec- ADDRESS - ' tion 7044,Bosfness and Professions Coda). � � � � � . . REQUIRED TOTAL SE7BACK FROM E%IST. � CONSTRUCTION LENDING AGENCY Sei enCK YARD HWY PROP.LiNE WID7H ► . , � I hereby afiirm thal Ihere is a mnslruction lending ogenty for FRONi � � �� �- tha per(ormonce af the work for which this permit is issved P.t. � � �Se[.3097,Civ.C.). SIDE ' ' � � � . P.L. . Lender'sNomeToronto Dominion Bank� �.� , . . .� �� . . 114 Sansome St., Suite 70D P.C.FeaS �3•�L PermilFee 67��� ' Lender's Address • � , . . � , �I cenify-thai I have read this opp itation and s�ate�hat the � - Issuance Fee /v�S� � � � � � � obova info�mation is mrrect.I ogree 10 comply with all Covnry inves+�gar�on Fee . r p � O O ' . ordlnances and Stota laws relatfng to building construc�ion, � To+al Fee V�tI• and hereby authorize represenmtives of this CouMy to m�er , , upon the o6ove-mentianed pro erty(or impection purposes. - � y��� `D n � ��h !Y . . � � � -� pcp � �V � �� � . , . SFE REVERSE FOR E%PIANATORY IANGUAGE Signaiure of Appticenr or Agem po e . . . . . .�t a . �. . _10 ° c� . �' r�� p l a �� - _`��,1 � a ' , ; `. �.v+ m a c, n; v is C� .a o n o � m c � � O c, T :i 0 •�. O 7 n, . ✓�� .aC. � o �t�i a; '� tf • �O �- � � �� O �,�1 '.C' i� 1 41 ' '� v . ,p N O m� � j' +7 p�.p �-'":',� m- � • . .0 _ '' tn 0 � 6� � y v . � �� .. 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