HomeMy WebLinkAbout0966A 0967A (5) l ,. , . . : . , ._ . ... .... _ ._.. ._ .......____. ___.. .__ - --..__..... . ......... --... _. . _ _ - .
� WORKERS'COMPENSATIONDECLARATION , � '+ �" "� � � � '.-" � ; '�:- G�
� .,. .. . ' � �
. I hereby aifirm that I hove a cernficote.oF�o�,e�,�a=e�� �� - -----�----APPLICATION ��FOR�.BUILDING- PERMIT �; '
� insure,or a cerfifica�e of Workers'Compensation Insurance, _
or a cenifled copy ihereof(Sec.3800,lob:C.) - COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
roi��Yr,o.61WETX79�m��y Hart or Gr0__�_I1D - g�I�DING
O Certi(ied copy is hereby furnished. fOR APPLICANT TO FILL IN nZ��II �'.
1 � ADDRE55 .
� Cerfified topy is Filed wiih IFie county buildin ins t- BUILDING
'IiOn dep/pi�Tep�t:' ' ADDRE55 24411 EdSt ThUnd .��� �
lDate�v�Applican GTY �1dtl10�dBd1' - - -z�p--- � -- ipCqIITY �
} � ' CERTIFICATE OF EXEMPTION FROM WORKERS" � � -� �� �� ------"�"'���8��5.- �� � ------ nlEnaEST- . ._ .._. ._._ ._-.--- ..,-....,
I `� � ' COMPENSATION INSURANCE � SiZE OF LOT NOW ON�Oi CROSS ST. , �
(Thls se�tion need�oi 6e complefed if the permit is for'o�e - - - � � - � -- �-- � -�- --- AUE550R. - � �
I hundred dollars(5��)or less.) . TRaCT " BIOCK LOT nlp. MAP BOOK� �� ��" PAGE PARCEL
owNeR Bramal ea Limi ted ---No. 850-1001 u$�,zoNe rnnc I
I 1 certi(y Ihal in�he performance of Ihe work for which lhis f�j�•� �� /��'� >
permit is iswed,I sholi not employ any person in ony manner Aoouess�-3151-Ai rwa �Avenue SU 1 te�N- - �:�� �� sceani � a
so as to becoma su6ject fo Ihe Workers'Compensalion lows. L �7 CONDITIONS u
•' ' _ , ... . ..... . . .. .. ..... .. _
� . '. .. CITY _. . ._._ 21P_. _ .."__' . .
Dote� ' ' � � Applicanl�� . ' . �
ARCHITECTO TE�• _.DISTRICT___ GROUP TYGE FIRE 7ROCESSEDBY... �
`JICE TO APPIICANT:`If;o(te�making this Certificate of ENGWFER �1ram Bassenian No.752-1 6 � �� - -� I
�4np�ion, yau should�become subject to the Workers' /� CON1SIi` Zl�O/j�F
�ompensalion pravisions of ihe Lobor Code,you mvsf forth- ADDRESS ��- '`�� -1'� -- ,(f� � 'd
with comply with such provisions or�.this peimi�shall be - TE�. � ' '�
deemed revoked. �. . .� � .-. . C SiATISTICAL CU1551FICATION , APT. CONDO.� ,Z
CONT2ACTOR Bramalea Cdllf No-8..0-1001 �
LICENSED CONiRACTORS DECLARATION - - - -,--- �- - ���C.-- -- MSS NO. U� DN'ELL UNIT$ ,
� I hereby affirm that I om licensed under provisions of Chap�er 9 AD�RE55 3�rj� Al l'Wa AVQ. N NO. �#� 6� SEWER MAP . • ;
(mmmenting with Section 7000)of Division 3 af�he Business and . __ _ _. . .... .. .. . . _ ���, . ... ..
Protesvons Code,ond my license is in full force and effecL CiTY Cw55 � � ��- BK. - - �'�� � VAIIDATION --
SQ.FT. NO.OF NO.OF CHECK
LicenseNumber ' '4096�0 lic.Class'' B ' size � STORiES FAMILIES � ONE
' � . + �. t�2�;���' � NEW -- .VAWATION : . _ . .
. . . . �� - --. . . _., .. . �
Cantraclor Rram�l�o� �nl i f Date - DESCRia � RK AD� S /�� '7� _(�C�(a(�n
/ /
❑I am ezempt under Sec. -$111 1 e fami 1 -Resi dence - A�TER ❑ �; ��' „ ` •��
8.8P.C.for this reoson N W Construction REPAIR � f �� ' � ' � ^J E�/i� '
--- te, USE OF DEMOL ❑
FXISTING BLDG. � ^ �J�(!1!� �.
--"'Sig�alure_ P � ' APPLICANT iEL. FINA�
O NER- UILDER DECLARATION PRWT No. 850-1001. oATE.� .
-I hereb offirm thoi I am e:em t(rom tha Cont c�or's litense qDDeE55 151 Ai Av . N C t FINAL �- ' .. L''�.��`�r'6 y
low for the(ollowing reason(Seclion 7031.5,Business ond � ' �
Professions Codej: - �� " " "-" ' RE N BY � - � . ' -
BUIIDING ' .
I, os ownei of the properiy, or my employees with ADORESS '
- - - - �- -.. ..:.- - � � - -- - �-
, wages as their sole compensotion,will do the worli and : ;
the strutlure is not intended or offered for sole(Section ��A��TY � ' .-�U�(y rf n
----- -7044,-BuslnessondProfessfansCode�.- �- � -"-- " MOVING �� ' �- -- - �- �� TEt: --�� �- - - - �--�
i CONTRALIOR NO. � �
� I,os owner of ihe property,am exclusively connacting � o e . . . 1��_
�w(th Ilcensed coniraclon fo construct the pro�ect(SeC- qDDRESS '� '
tlon 7044,Business and Prafessfons Code�. . � ��(1 Q,G O
� . . ._.. _ .. . _RE�UIRED.. YARD' HWY' ' �OIALSETBACK FR M. %I i. .. . .
�CONSTRUCTIONLENDINGAGFNCY�� � ��'- seieaa PRpP.�ME wiorH � � -" � �� � "��'- -�
I hereby oifirm thot thera is a cons�ruUion lending egency for FRONi . �' s:'''�'�7��� '
' -Iha performanca of ihe work Fo�which ihis permif is issued ... .. P.l:..-_... _ . . ._.._... ._._. ._. . . . . __...._"'_'_—"'_...__., . . . "_ '- .
[Set.3097,Civ.C.). SIDE ' �i;C Q'���� '
m lender'sNome Toronto Dominion Bank �- °L'
s' 144 Sansome St., Suite 700 _ 3,2a•S!/ .- P��,;,feQ ��:3ZJ,,.. . LDMARef.M
� Lender's Address � � P.C.Fee f �
> s Y�7���
ffi I certify that I have reod lhis applitalion ond stale Iha�the . - V�v��'�'/.�� -����� � Hwonce Fea-� Id�"s�-- ��MA 7�C X -- - � - - ' ��- � ' � � ' ' ,
_ . . .. . . .. ..
a obove informotion is mrted.I ogrea b comply wilh oll Couny Invesngarion fee q '
� ordinances and State laws relatin to 6oilding tonsvuUion, Tmal Fee- � ✓���-O� - IDMA perm.M -
- .__ - . . ... .. .. _. . ... _ ... _. ._ ., ,
and hereby au�ho'a repr sentaf es his County to anfer � � �
au �
upon Ih a6ove- nfi ne prop y speUio pur ses. ._. .. . ..... . .��A . . . . � _ . . ..__ ,
a SEE REVERSE FOR EXPUNATORY IANGUl1 E �
0
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