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HomeMy WebLinkAbout1147A 1148A .. ._ __ .� WORKERS'COMPENSATION DECLARATION - . . . � ��� - _- � , , �. - .,. - � - �- J'� � � �� � APPLICATI4N FOR BUILDING PERMIT '� I hereby aftirm�hot I have a tertificate of consent to seif ' insure,or a cerfificote of Workers Compensa�ion Insurance, � or a certif�ed topy thereof(Sec.3800,�ab:C.) COUNTY OF LOS ANGELES BUILOING AND SAFETY� v,i,�,.No.61WBMX75a1�Em��Y Hartford'Group a Certified copy is hereby fumished. � � . fO •APPLICANT,,TO FILL IN BUILDING 24352 East Nan �OUPt . ADDRESS � Certified mpy i1 filed wifh the county 6uilding inspac- ' -�� BUILDING .L -- ro�dePanme�t. - nooRess 435'� EdSt Ndfl COUI"t oere 7-74-R7 nPPi��am_ Bramalea Calif, cirr p.B. H711 ziv �ocauTv D.B. Hills CERTIFICAIE OF EXEMPTION FROM WORKERS' � � - ��- - �- �� � �-� - �NO.OF BLDGS.. _. .- . . � NE.e.aE57 � - -COMPENSATION INSURANCE .. � _ SIZE OF LOT �' NOw ON LOT � CRO55 SL � (This seclion need not be completed if the permit is for one - - TRACf 42575� g�p�K - "- l0T NO. -2$ f �ESSOR � . � . hundred dollors{EI00)or�ess.) . , hV1P BOOK� � VAGE PARCEL • . � . � TEI. � MAP - I certify Ihot�in the performonce of the work(or whkh this �� OwNER � ---- O. - ��� � ; � _J7(� permlf is i75ved,I shall not employ dny person in ony manner AooREu� 3151 Ai rway Ave.� 7tN SGECIAL , � ' so as to 6ecome s�b�ect fo the Workers'Compensation Lows. - � - OdP C� CONOITIONS 0 c�,v Costa Mesa z�P 92626 �' Date�� .. .. Applicanl � . . . - . . . fL' "roTICE TO�APPUCANT: If, afler making�ihis Ce�tif(cole of ENGHNEER �R ' Np _ DISTRICT GROUP ONSL � ZON PROCESSEDBY � bmption, you should become su6jecf to the Werkers' �mpennation provisions of tha labor Code,you mvsl forth• pppqE� 3990 Westerly Place #17� �� R 3 � W with comply with svch provisions or Ihis permit sholl ba � (1, . deemed revoked � . TE�• STATISTIGAL CIASSIfICATION" APT. N�O. tA CONTRACfOR B Np. �L.� Z UCENSEDCONTRACTORSDECIARATION - . . . ���•'409610 QASSNO. vt/- DWELL.UNITS� � I hereby offi�m that I om licensed under provisions of Chopter 9 ADDRE55 NO. ��R�P (commenting with Saction 7000)of Division 3 of rhe Business and ��� B � Professions Code,ond my license is in full force and eHect. - ciN -J .- -� �,55 �� BK .- � . VALIDATION - ticenSaNumber � 4O9f1O - ' ���,[Iass B� "� �E�G'- -.sroR°s -2 Fn°i�°is �1 oNeK � �. � v�w�noN OIB Da�e �ES�RIPTION OF WORK N� CoMrotlor � ADD � s , �� � �,�]A ❑I am exempt onder Sec. � - ... $FR . _ . _ PLAN 25� A`�cR #. . . .21 B.BP.C.for lhis reosOn REPAIR � ' s 1S3 - .. Date:- ..... EXISTOING BLW. - D�a ❑ J� � ��,� Signotore . .. . . . .. . APPucAr�T � tEl. FINAL G I •4 1 a 2 3 OWNER-BUILOERDECL4RATION PRiNT Bramalea Cd�lf. NO. $5�-10�1 DATE �d�/a � I here6y oftirm thol I am ezempt from the Contmclor's Licensa - qooRE55 3151 Al1'Wd AV@. �N Costa Mesa ° '�� '�2 3`_' low for�tha loilowing reason(Sec�ion 7031.5,8usiness and FlNAI �� ' Professlons Code): � � � �- -�- N � - -- Sy . ��Q 8�-$'] ..� . BWIDMG . .. . . _ . � . .. I, as owner of�he properry, or my employees with aooaess . wages as thair sole compensarlon,wlll do tha woik and , the slroctore is nol intended or offered for sale($ection ����TY �'- �.� � '�� � - - �� 7044,Business and Professions Code). . . ..- . . - MOVING- -... . - - - .--..... TEL .. . .=-�"` �':. . �' ��. .' . . _ _ � I,as awner of tha properry,om exdusive�y mMroUing CONTRnCTOR� NO. - � , � with licensed contractors to tonstrotl the project(Sea ..-. .. ADDUE55 . _. . . . . . . .. . - - . � . -- '�� �-�'8 A , tion 7044,Business and Professions Code). - � � RE�UIREO TOTAI SETBACK � �� � #� ••�• •� � CONSTRUCTION LENDING AGENCY � �� SET BACK �ARD -HWY � PROP.IINE Wi�iii �� � � i hereby affirm thellhera is a construction lending agency for FRONT I ♦"�Q��� ., � ; '�,` � , fha performonca of the work for which this permit is issoed . .. v.l, - .-..-- . . . . . . � . .. � ' - . � (Sec.3097,Civ.C.). SIDE • e'���Q O� Toronto Dominion Bank P�` ' lender's Nome �/ �' . San Franei sco Cal i f. P.e,Fea s -- 'y'� 69 .S� IDMA Ref.k ' 0�2$`8 7 Lander':Address s - � "- T� Permn Fea- _�. � ,�� '�' � � .. . . . 1 cenify thot I have read this applicatian ond stata that the . .. _ ___ �S.00 . Issuance Fee__lO.5O_ , LpMA p/C N_ � obove inlwmaiion is torrccr.I ogiae to comply with all County invesugmion Fee ��7 ordinances and$tafe laws rela�ing fo boilding tonsfruttlon, _ _ . ioml fee..- �'--""'NS� .��,�p,perm.M- � � ond heroby outho�ixe represenfatives of this Covnty to enter � - - � � - - � � - upon Iha a �v - enti e perty for inspec ion pv oses. � � �. . - � . �-�� ... ._ . . .. . . . . . ?�� ..�, .� . ,. . . SEE RFVEISE FOR f%�UNATORY UNGUAGE `�J � �gna e i pp icont or Age�t � po . .._ . . . .. . . . . . . _ . .. - .. . . z o - o ' . . _ �, l�, "ry � '� `' � . . _' � N�' 0.,.�a' � iO �� �,� , , O ... � 'n� 7 R 0�,. f4 � .�O • . � fl � n � v �,. � � �o o \. G 7 ^ �^. .� � o '� .c . -o ,f .O J 9. p O. ' '�y 7 � 'Q�'� T' ' -� n? � rG_ � .',." 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