HomeMy WebLinkAbout6923A 6924A (18)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No.61WBRK44%mPany Hartford, Group
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
ti n deportment.
Date Applicom '
ERTI CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOT, TO APPLICANT: If, after making this Certificate of
nption, you should become subject to the Workers'
pensation provisions of the Labor Code, you must forth-
with ceosp!y with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chop^er 9
commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number
409610 Lic Class B
Contractor Bramalea Calif.Date Qfik953
I am exempt under Sec.
B.BP.C. for this reason
Dote:
Signature _
7
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's C
Low far the following reason (Section 7031.5, Busine n
Professions Code):
I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
ZSec. 3097, Civ. C.).
Lender's Name Toronto Dominion Bank
144 Sansome St. Ste. 700
Lender's Address
ll CIcertifythatIhavereoEdtisapplication an state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
Signo^ure of Applicant or Agent J. I Dote
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING
G . + n0eafss Y'' G 717 . LX
BUILD'NG
ADDRESS 24409 E. P,nInge Cour LOCALITY
Diamond BarCITY ZIP NEARESTCROSSST.
NO. OF BLDGS. ASSESSCR ISIZEOFLOTNOWONLOTMAPBOOL PAGE PARCEL
42565 1FLOCK 36 ; UAfgICN°
TRACT Lor No.
OWNER Bramalea Ltd. NO. 850-1001 06 C)
SPECIAL
CONDITIONS
DISTRICT GROUP IYPEFIRE PROCESSED BY
ADDRESS 3151 AirwayAve. Suite N CONST. z
R-3 Y -m 2--r
CITY zIP
STATISTICAL ASS'FI TION I DO.
ARCHITECT TELARCHITECTBassenian 752-1864 f—
rNGINEFRAram No. CLASS NO. DWELL. UNITS_
ADDRESS 3920 Westerl.v Pl. Ste. 170 SEWER MAP
Bramalea Galif. TEL 850-1001 PG, VALIDATION
CONTRACTOR NO. eK.
ADDRESS 3151 Airway Ave. N vo: 409610 VALUATION
Costa Mesa, CA tic.BCLASSCITYs
SO. FT, i884 NO. of 2 NO. OF 1 CHCCK'6923SIZES7CRIE5FAMILIESONE
ppqq ((. DES§0f1ON60F'7YORK Plan 23B ' NEW ® 6 O/ G 1
Single Family Residence ADD 2 Q A 1
ALTER FINAL
New Construction -
REPAIR
DATE 3 G U 1. 1
USE ofFINAL
EXISTING BLDG. none DE'SOL
APPLICANT.—...... T AT.t..... IFL_ Glut —t nnl
By 2 8 — 8 6
3151 Airway Ave. N, Costa Mesa ,
ARA
P.C. Fee 5 • ^' Permit Fee 15-39
1--e Fee /d _S
lnvesligonon Fen IT.I.1 Fee
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