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HomeMy WebLinkAbout0667A 0668A WORKERS'COMPENSATION DECLARATION _ � I hereby affirm ihaf I have a certificate of consanf to self APPLICATiON FO�R BUILDING PERMIT insure,or a certifica�e of Workers'Compensation Insurante, or a certified copy thereof(Sec.3800,Lab.C.) Poi��YN�6IWBRK4484comPo�Y�lartford Grou� COUNTY OF LOS ANGELES BUILDING AND SAFETY BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 I�fJ K%xk.C4.��.� •�. �Certified copy is filed with the county building inspeo- BUILDiNG y(� y� J�on deparimenL ADDRESS 1401, S. Stonecrest Place IOCALITY .Cd-"�• Diamond Bar NEAREST �ate Applimnt 7 ..w..-�.� CITY ZIP CRO55 ST. ERTI ICA OP EXEMPTION FROM WORKER5 � NO.OF eLDGS. ASSESSOR COMPENSATION INSURANCE S¢E OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This secfion need nof be complefed if the permif is for one US qNE MAP ql�� hundred dollars($100)or�ess.) TRACT 42556 s�ocK ior No. 29 �N� No. �i owNeR Bramalea Limited N�14850-1001 p��p�aJ�� CONDITIONS � I cerfify ihat in 1he performance of fhe work for which lhis DISTRICT GROUP TYPE F�RE PROCESSED BY � permit is issued,I shall not employ any person in any manner ApoREss 3151 Ai rway Ave, Su i te N coNST. zo � so as to bemme su6ject to the Workers'Compensation Laws. �Q �� , �, ��TY Costa Mesa Ca z�P 92626 � DafC AppliCani STP.T�51'ICAL CLASSIFICATION AP�. C NDO. � "��TICE TO APPLICANT: If, after making this Certificate of /aRCHITECT OR TEL _ ENGINEER N C1A55 NO.�DWELL.UNITS�L � mption, you should become subject to the Workers' �3 _ompensation provisions of fhe labor Code,you musi forih- qODRES53g9O W2St2r��/ P�� SUIt@ 1]Q SEWER MAP � with mmply with such provisions or this permit shall be � deemedrevoked. coNrRncior$y'dllld�2d Calif. N`'di 850-1001 BK �. VALIDATION LICENSED CONTRACTORS DECLARATION 3151 Ai rwa Ave, N "`.409610 (�U,��H I hereby affirm thai I am licensed onder provisions of Chapter 9 ADDRE55 .y NO. VALUATION =V (commencing with Section 7000)of Divisio�3 of the Business and ��� J ry Prafessions Code,and my Ilcense is in full force and effect. Ciiv COStd �25d� CA 92626 CLn55 g S !b� (� ► �ti° " ` s C� SQ.FT. NO.OF NO.OF CHECK License Number 4n9h1.n Lic.Class R srze STOR�es FAMILIESZ on7e � �>�.'�v.�� / / DESCRIPTION OF WORK NEW � � '�J(���j. I C co���a�,o�Bramalea Cd�lf. Date 6 6 85 ❑I am ezempt under Sec. 5111 1 e Fami 1 Res i dence A��R � F,NA� �(z 1 3_�.5 B.&P.C.for this reason REPAiR � DATE �y�0/�Sl Oofe: USE OF none DEMOL ❑ F�NAL EXISTING BLDG. si9oot��e — �` • "PP�PRiNrTBT^uCe L. Abbe ni�"d14850-1001 eY -``rbf°A OWNER-BUILOER�ECLARATION I hereby affirm that I am exempt from ihe CoNrpd s Lic n qDDRESS 31�J I. A1 Y�W1 AV2 N Costa Mesa � �a � a a c � Law for ihe following reason(Saciion 7031.5,B and 7rofessions Code): PRESENT � "��%��n�'t�(i BUILDING � I, as owner of the property, or my employees with ADORE55 y �,>>�.U{;!)�: , waqes as their sole compensation.will do ihe wark and the siructure is not intended or offered for sale(Section LOCALiTv ��� _v��` 7044,Business and Professions Code). MOVING TEL. ' � I,as owner of fhe properiy,am exclvsively coniracting CONTRACTOR NO. - , with licensed contractors to constr�ct the project(Sec- qDDRE55 tion 7044,Business and Professions Code). � . REQUIRED TOTAL SE76ACK FROM EXIST. CONSTRUCTION LENDING AGENCY SEi sncK 1'AR� Hwv PROP.LINE wi�7H , I hereby affirm tha�there is a consiruction lending agency for FRONT the performance of the work for which this permit is issued p.�. ' �Sec.3097,Civ.C.). SIDE � � � Lender's Name Toronto Dominion Bank P�` 144 Sansome St, Suite 700 p,C.Fees �3� ��m��Fee �"3$'� Lender's Address � ' . ' I certify that I have read this application and stme thm the issu ce Fee ��`�� ahove information is rorrect.I agree�o comply with nll County i,,,,es��gar�on Fee tln �y �� ordinances and State laws relating ta building construction, Totol Fee � � � . �. and hereby authorize represen�atives of ihis County to eMer . . upon the above-mentioned property for inspection purp ses. �„�,�r � � � � SEE REVERSE FOR EXPLANATORY LANGUAGE oture of Applicant or AgeN Date �� �.' q � .__ ;���._ T NS��^.� -- --'-----y -_--i------�" -- ; —{..%.�___..�---;--'-Y--'---'--- { ; �� 9�' ��"a Q p � � j �� � ~� � �cn ; ;, .. �`;Z „ n � .� �' �!a g fEE ro � c � �� � � :j�i� � !-S¢ � � � � � C iIM O!� � a x�- � �� � � f�. � O � �" Q �� � '�3 '� � I � ' �= -� 4v `.D 2 1�' .i� � s 6 _. �..,.:i � :i ; _ l _�...1.-_... �j rn �K . 3 G n �f �" : (fl � Q �_ � c �,:. � .,°� � S � � � �'p� � E1? � � i �r. sN _a, � I � z � C �i n , " fl � � � �� I �� �' y I � ��.3 � c`i{ ;j _ � ! ° 3iv � t+ � ; I % ��, �� f.a � Z j �. � _ � �; i _ �: �`„�� a' v � :? . f �Q I� �^ f ` i -' � � � � e �. � n''' � =� I �� 3 1(�• � � I {{ Q 3 � �=,- �! m 1 � J � � .M � 3 I G 3 .C' � f� ~ � E i !�� ;: ! v� .��Y � CJ � (C"� � _ I •� 1... � � � � � � � ' :, , �, � � � � ; ;�. � ' � , ��,i � 'i 3 I ! ..�_ � J_.__�_�_�____.� � �, � �� o ! i � � c-'---�� �. 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