HomeMy WebLinkAbout3921A 3922A (15)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 No61WFTXZ92,lompony HARTFORD GROUP
Certified copy is hereby furnished.
Tc'
ediop
y is filed with the county building
inspec.epent.
e Applicant
C TIF TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Thls 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
NOTICE TO APPLICANT: If, after making this Certificate of
itption, you should become subject to the Workers'
ipensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 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 Dote
I am exempt under Sec.
B.BP.C. for this reason
at .
Signature
OWNER- UILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, or myemployees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Businessand 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
7Sec. 3097, Civ. C.).
Lender's Name TORONTO DOMINION BANK
144 SANSOME ST., SUITE 700
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby outhoriz represented s of this County to enter
upon th ab - e bone pro t for Inspect ses. tio
purl" nature of p m nt or Agent ` par
APPLICATION FOR
COUNTY OF LOS ANGELES .
BUILDING PERMIT
BUILDING AND SAFETY
IaZ 9
FOR APPLICANT FILL IN ADDRESS C.
BUILDINGADDRESS 24445 EAST THUNDER TRAIL I •;
1
rLOCALITY , h
NEAREST
CITY ZIP CROSS ST.
NO. OF BLDGS. ASSESSOR
S1ZE OF LOT / NOW ON LOT . MAP BOOK PAGE PARCEL
TRACT 42568 / ISLOCK LOT NO. 29 ! USEZONE
fzpv NOP
TEL.
OWNER NO. Zpf DIS SPECIALCONDITIONS
3151 AIRWAY AVE.,SUITE N
DISTRICT GROUP TYPEFIREZONE PROCESSED BY
ADDRESS -
9 3 121CtrYCOSTAMESA, CA zIP 92626
ARCHITECT OR TEL.
STATISTICAL CLAS.S IF.IC.A TION
1 jr
APT. CONDO.
ENGINEER NO. — CLASS NO.,y DWEII. UNITS_
ADDRESS 3990 WESTERLY PL. SUITE 170 SEWER MAP
CONTRACTOR BRAMALEA CALIF No. 850-1001 BK. PG. VALIDATION
LIC,
ADDRESS NO. VALUATION
COSTA MESA, CA CLLASS B s fs"a1 D 3 9 2 1 Aclry
SO. FT.NO. OF NO. OF CHECK21 2 1SIZESTORIESFAMILIESONE
DESCRIPTION OF WORK PLA ! NEW ® I • .9282
SINGLE FAMILY RESIDENCE ADD p 3 2
NEW CONSTRUCTION REPAIR []
ee
DA
EL
ao •` G I 1,24-86
USE OF_
DErAaDI
FINAL
EXISTING BLDG. ---- - - - --- ._.... ..
APPLICANT n nn .•rn , TEL. nom,.- gy
00.
3922A
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1. 1 5600
1_Q003
1,24-86
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