HomeMy WebLinkAbout1161A 1162A (5) . WORKERS'COMPENSATION DECIARAiION �� � � �
I hereby oli�rm,�o,1 hove a cerlificote ef�o�se�„o,e�f � -� APPLICATION FOR BUILDI NG PERMIT
� insure,or a ce�tificate o(Workers'Compensa�ion Ins�rance,
or o certiiied copy rhereo{�Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUILDING,AND SAFETY
PolicyNo61WBMX75�@�mpony Hartford Group - ' �
� Certitied copy Is hereby f�rnished. � FOR.APPIICANJ�TO FILL IN ADDRESS z4376 East Nan COUt't
� Ce�tified eopy ts filed wilh the county boilding inspec- BWIDING / � -
tion depa��ment. ADDRESS 24376 East Ndn Court
oo�e 7-24-87 Applicon� Rramalea f.alif. arv z�r iocauTv D.B. Hills
CERTIFICATE OF EXEMPTION FROM WORKERS' - � NO.OF BIDGS. .. � Ne.aeESi , . . _ _
COMPENSATION INSURANCE .. SIZE OF t0T / NOw ON LOT / CRO55 ST.�
(Thls seclion need nol be compleled if tha permff is for one � 7RACi 42575 �I BIOCK � LOT NO.26 MqP BOOK PAGE PARCEL
hundred dollors(5100)or less.) .
I tertify ihal In iha performance of the work for which this
OWNER Bramalea Cdlif., It1C.No850-1001 u��� �P � _��
permit is Issvad,I shail nol employ any person in ony manner 3151 Ai rwa AVe. #N n_ SPECi.nl � ._
ADDRE55- Y � �-(JOO�7 CONDITIONS
so os�0 6emme subjeet to Ihe Workers'Compensalion lows. - V
oaia naa��co�i � ciTr Costa Mesa z�P 92626 a
"QTICE TO APPIICANT: If, ofter makin lhis Certifitole of ARCHI7ECTOR Aram Bassenian TE�•752-1864 DISTRICT GROUP TYPE FIRE PROCESSEDBY O
��mption, you shou�d become su6ject to the Workers' ENGiNEER NO.
,fj mNs. z V
�ompansation provisions of the Lobor Code,you mus�forth• ADDRE55 3990 Westerl y Pl ace #1�� lv Y�—�J " � � W
wllh comply wilh Su[h provisions or this permit shail 6e TEL. STATISTICAI C(ASSIPICATION APT. CONDO. (�/7
deemed revoked. . �pNTRAttOR NO. � ' �--f Z
LICENSED CONTRACiORS DEQARATION - -- . . ���• 409610 . CtA55 NO. DWEIL.UNITS_�_.
I hereby oNirm that I am licensed under provisions of Chap�er 9 nD�RF55 NO. ��R�p
(tommencing with Section 7000)af Division 3 of the Business and ���� �B . � VAUDATION
Professions Code,and my license ie in full force and effect. CITV ��' BK. �PG.
SI�ZEFT_ Z 5 ORI�ES � FAAIILOIES 1 � CO EK�
License Numbe. 409610 � u�.aass � B� � vnwnrioN
��B � �Dole ' � � " �ESCRIPiION OF WORK� N� - S -�—+1AA .
Confra[tor ADD � u;��������
�I am eaempf under Sec. . SFR . - ALTER � , �� � �� �
B.BP.C.for rhis reosori PLAN Z5� aevaie ❑ s ����C7 #• •+ •2 1 .
pa1e: , - USE OF DEMOL ❑
� E%ISTING BIDG. - I •�1� 7J.2 J
$ignolure - AP�pRt TT Bramalea Calif. No. 850-1001 FINAL 3/ 9��� _
OWNER•BUILDER DECLARATION DATE � ... .. • .�7 3.2 3 c�
I here6y offirm that I am exempt from ihe Comractor's License �- qooRe55 1 I Ai rwa Ave. N Costa M Sa FINAL�
Law fo�rha following reoson(Sec�ion 7031.5,B�siness and Q Q 2$—$7
Protesslons LodeJ: � -� - � �� -- --- Pe 6Y �
� BUILDING
I, as owner of tha property, or my employees wilh nODRESS
wages as their sole compensation,will do the work and ,
�� the elrutfore Is not Intended or offerad for sala�Section ����TM _ __, . ' .
7044,Business and Professions Code). � � � - MOViNG - �-� TEL. - '
� I,as owner of Ihe property,om axclusively contracting CONTRnttOR NO' �� � � �� � Q 2 A
with litensed tontrotrors to consrrutf the project(Seo- qDDREss� �•- '' ` • � � � -
fion 70<d,Business ond Professians Coda). ' , . � � .
REOUIRED iOTAt SETBACK FR M - •- - f�• • • • • �
CONSTRUCTION LENDING AGENCY � ' SET BnCK YARD HWY 7ROP.LINE WiDT11 ' � - . � �
I hereby affirm that there is a construclion lending agency for FRpNT . _ I •'�O rj,O Q
fha performance of the work for which Ihis permit is issued -- P.L - " ' � .
(Sea 3097,Civ.C.). SIDE �.:•+,, , .,.•. • �7 Q a O Q,—�
P.L. .
lender'sName Toronto Dominion Bank
t�.� .y3 �g .� mn.w a�i.w •. 0 t�2�3`-8 7
lander'sAddress San Francisco. Cd�l'F. P.C.Feet ve.�++tiP�e ;
I certify tha�I have read this applicetlon and state�ho<<r,a _ 75.00 li�uonce Fee 10•50 �DMA p/C N ��
above informaflon is tonett.I agree lo comply with all Co�nty Investigotion Fee
ordinances and Stote Idwe teloling�0 6uilding construttion, Torol Pse � �' �L�MA verm.X � �
and hereby o thori rapre ntatives of this County�o entar '
upo I� o� e-me o e ope.ty for inspeclion pvr oses. � ✓ � . � ,.
�V
SEE REVERSE FOR EX►UNATORY LANGUAGE
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