HomeMy WebLinkAbout1107A 1108A (5) � � �
WORKERS',COMPENSATION DECLAR.4TION �•.
Iinsureborafcertifca�teofWokesrtCompensatoninsurancef APPLICATION FO�R��--SUILDING PERMIT
or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑olicyN�lGTIiRK4484Company �rFORD GROUP BUILDING ���r. �„7 g
Certified mpy is hereby furnished. FOR APPLICANT TO FILL IN qooee�s--- �
� Cerfified copy is filed with ihe caunty 6uilding inspeo- BUiLDING .f�S ,
fion department. ADDRESS 1401 S. Vt1LEVI�W DR. �ocnurr o�
NEAREST
Date �J�^Applimnt � CITY ZIP CROSS ST.
ERTIfI ATE OF EXEMPTION FROM WORKERS' . _ NO.OF BLDGS. _ ASSE550R
COMPENSATION INSURANCE SIZE OF LO7� � , NOW ON LOT MAP BOOK PAGE PARCEL
(This sedion need not 6e campleted if ihe permit is for one USE ZONE MAP
hundred dollars�$too)a�less.� TRACT 42556 BLOCK ior No12 No. ' ` 3�
TEI� 1 SPECIAL 7'
I cerlify ihat in Ihe performance of the work for which this OWNER g L A LIM T Nd��04� CONDITIONS ��
�ISTRIQ GROUP 7YPE FIRE PROCESSED BY �
permit is issued,I shall no�employ ony person in any manner ��������3551 AIRWAY AVE. SUITE N CON ZO�yE �
ADDRE55
so as to become subject to the Warkers'Compensmion Laws. rO �� � T �
�,TY cosTn r�s�, ca. Z�P ` �
Date Applicanl STATISTICAL CLASSIFICATION APT. ONDD. �"`
NOTICE TO APPLICANT: If, after making this Cerlificate of ARCHITEC70R TEL. �
' a;yotion, you should become subject to ihe Workers' ENGWEER AItt�7 BASSENIAN r,o.752—Z864 C1A55 NO- �� DWELL UNITS�_ 5"'
2,
��pensation provisions of ihe labor Code,you must forth- qpoRE553990 WL''STL''RLY PL. �F'17O NEWPORT BC . sewea nnAP �
.wdn comply with such provisions or this permit shall be �
-;deemed revoked. CONTRACTOR BRAMALEA CALIF. N� �— �OL BK. PG, VALIDATION
� LICENSE�CONTRACTORS DECLARATION S g��IC.
'I hereby affirm ihat I am licensed under provisions of Chapter 9 ADDRESS 3151 AIRTdAY AVE. � NO. 0 61� VALUATION -`.� � ; � I ��
`(commencing with Settion 7000)af Divisiol�3 of Ihe Business and ���. S �� �D O
.Professions Code,and my license is in full force and effect. CITY CLA55 ► �:)e m e �+i�
. SQ.FT. NO.OF NO.OF CHECK
License Numbe�+O9G1O Lic Class R S�Ze 1637 SioR�es Z FAMILIE51 ONE � W���(�,�
S
�Conifa[tof BRAMhL�A CALTF. oate�� DESGRIPTION OF WORK ZZ CR NEW � � � � � �; -
ADD
❑ ,`/i ..
'❑I am exempl under Sec ' ' AITER ❑ PINAL �1�����'��`��
B.&P.C.for this reason NEW CONSTRUCTION REPAIR � DATE J'�� �/(r
� Date: � EXIST�ING etOG. NONE DEMOL u BY AL
Signalure_� .�—� � i4PP���'"r BRUCE L. ABSL+Y rEi.
OWN R-BUIIDER DECLARAiION PRINT NO. — OOI. ' � � C rC A.
I hereby affirm that I am exempt from the Comracror's � 3151 AIRWAY AVE. N. COST A�C . , ti e = �� j
,Lqw for the following reason(Section 7031.5,Business an ADOReSS � g �
`.Professions Code): Y P SENT � �:G � L �('�
+: BUILDING
:6� I, as owner of ihe property, or my employees with ADDRE55 � p : f �, ` ,..
, � wages as their sole compensation,will do the work and ' ` ��•�-
�= fhe sirudure is not intended or offered for sale(Section ��ALITY
�-/� 7044,Business and Professions CodeJ. MOVING TEL � ��L["<<
.�p(� I,as owner of ihe property,am exclusively mnfracfing CONTRACTOR NO. ,
`�'� wi�h licensed com�actors to construct the project(Sec-
tion 7044,Business and Professions Code). A�DRE55
REQUIRED TOTAL SETBAIX FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YAR� HWY pROP.LINE WIDTH , �
I hereby affirm that there is a mnshuction lending agency for FRONT
the performance of the work for whith ihis permit is issued P.L.
�Sec.3097,Civ.C.). 51oE
P.L.
�ender's rlame TORONTO DOMINION BANK
� 11�F SANSOME ST. SUITE �OO � v.cFee$ ������ Pe�m�1Fee 7 -��
= lender's Address vn nrrn na i ni
� o�,'�-,-�a-aQ��6E9>zff��rvg ().S?J
I certify that I havenread rhis application and state that the Issuance Fee �
a above information is correct I agree to comply with all Counly Investigation Fee � � ' `.�
g ordinances and State laws reloting 10 6uilding construction, Toial Fee ��
� and hereby authorize representatives of this Coumy to enter
� upon ihe a6ove-mentioned property for inspection purposes. n `�G `�.'�,�,sY
,p nl J �,—'/ '( �
n �-�_i..M� .d 1� p SEE REVERSE FOR EJ(PtANATORY LANGUAGE
Signa�ure of Applicant or Agen� Da�e �f
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