HomeMy WebLinkAbout1101A 1102A WORKERS'COMPENSATION DECLARATION "�
I hereby affirm that I have a cer}ificate of consent to self qpp`�CATION FOR BUILDING PERMIT
insure,or a certifimte of Workers'Compensation insurance,
or a cerlified copy ihereof(Sec.3800,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAPETY
PolicyNo61WBRIC448�ompany HAKTFORD GROUP
� Ce�tified mpy is he�eby furnished. FOR APPLICANT TO FILL IN aunoiNc, c� �Jp � 'fj
ADDRESS � /�`� • LO�i.-��T<^��' �{�',2"
� Certified topy is filed with ihe county building inspeo- BUu�ING
tion deparlmenL ADDRESS � LOCALITY �•�•
Date�B�n ucanr _ . X. aTv DIAMOND BAR NeAaesr
PP ZIP CROSS 57.
CERTI ICATE OF EREMP710N FROM WORKERS' NO.OF s�oGS. a55E5SOR
COMPENSATION INSURANCE SRE OF�Oi NOw ON tOi MAP 800K PAGE PARCEL
(This section need not be completed if Ihe permif is for one 1 USE)ONE MAP )`/ .3
hundred dollars($100)o�less.) TRACT BLOCK LOT �e�aJ No. 'i �''
I certify�hm in the pertormance of the work fo�which this owNeR BRAMALEA LIMITED No.$50-1��1 o�f)Oa CONDITIOnlS �
permit is issued,I sholl noi employ any person in any mpnner 3151 �1IRWAY AVE. SUITE N D�S7RICT GROUP TVPE FIRE PROCESSE�BV �
so as to hecome subjecf fo fhe Workers'Compensation Laws. ADDRE55 (� �T�CONST.� � �
�are A limnt arv COSTA MESA, CA. ziv 92626 � �
PP STATISTICAL CtA551FICATION APT. CON O.
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT oR TEL LF .y,t �
" tion, ENGINEER NO. - $ CLA55 NO. � DWELL UNIiS � � �
p' you shoold become su6ject to ihe Workers'
pensation provisions of the Labor Code,you must£orih- qDDRE5S3J9O «EST�RLY PL. �IL�O NL'WPORT BC . SEWER MnP "'�
wit comply with such provisions or ihis permil shall be �;
deemed re�oked. coNrkncTorzSRtlP�f1LEA CALIE. Np sK. v�, VALIDA71tlN �
LICENSED CONTRACTORS DECLARATION ,���
I hereby affirm fhat I am licensed under provisions of Chapfer 9 ADDRE55 3151 AIRWAY AVE. rvo. 409610 YALUATION
(commencing with Section 7000)of Division 3 of the Business and ���, >` i J.� �
Professions Code,and my license is in fuli force and effed. CITY CQ$T,� T'�'$A C/�.. 92626 CL4S5 B $ ��f � Q , �
SQ.FT. NO.OF NO.OF CHECK �.;a w .. o�j
License Number 409610 �;�.class B s¢e sroRiEs FnMaies orve
T�' �(��L�,�-" DESCRIPTION OF WORK 23 B NEW s� $ � '�%G O,�` 1
Contracto�_ BRA.�ALEA CALIF.Date
I ❑I am exempt under Sec. �r SINGLE FAMILY RESIDENCE ADD � ' ��`��"� ' �
AI.TER � FINAL
B.SP.C.for this reason NEW CONSTRUCTION REPAIR � DATE �'�� / U l,(,�%"�'rJ
I Date: USE OF NONE � FINAL
EXISTING BLDG. DEMOL B
$ignafure • APP��CANT TEL.
Y
OWNER-BUILDER DECLARATION PRINT SRUC� L. ABBEY NO, - OL c_� 1 (1 C A
. I here6y affirm that I am exempt from the Comra ' ' nse 3151 AIRWAY AV�. N. COSTA MF,SA C . ,
�, Law for the following reason(Sedian 7031.5, usiness and /+DDRESS 7.f,� a c o a �
I Professians Code): PRESENT
���. � BUILDING I °v Q.Q�L'
I, as owner of the properiy, or my employees with PDURESS
wages as iheir sole compensation,will do the work and � t�ll�1,�j(��;,
the structure is not intended or offered for sale(Section �OCALI7v ,
7044,Business and Professians Code). MOVING TEL.
� I,ps owner of the property,am exdusively conhacfing CONTRACTOR NO. � /.C[-s '�,r`
wifh licensed coniraciors ro construct the project(Sec- qDDREss
tion 7044,Business and Professions Code).
REQUIRE� TOTAL SETBAIX FROM EXIST.
CONSTRUCTION IENDING AGENCY SET BACK VARD Hwv pROP.LIN WiDiti ,
I hereby affirm that there is a construction lending agency for FRONT
ihe parformonce of the work for which this permit is issued P.L.
(Sec.3097,Civ.C.). SIOE
P.L.
�endei s Name TORONTO ➢OMINION liANK
$ P.C.Fee S ��O� T I P¢rmit Fea �.'2�rJ^-��
lendeisAddress SAN FRANCISCOy•CAL. 941�Lt /
� I certify that I have read this application and state}hat the Issuance Fee 6 t���
¢ above information is correcf.I agree fo tomply with all Counfy Investigoiion Fee ,/�e ��
`� ordinances and$tafe lows relating to boilding tonstruction, Total Fee �7
�i and hereby authorize representatives of this Coumy to enter
� upon ihe above-meniioned properry for inspection purposes. � /O� ��A� ��
� -'�'(� d1 ///��� f� 6
y'��t__ -�g, � (�f7/f�+j�- SEE REVERSE FOR EXPlANA70RY LANGUAGE
Signatura of Applicam or Agent �Dot�-'� m,
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