HomeMy WebLinkAbout1159A 1160A WORKERS'COMPENSATION DECLARATION
I hereby affirm �ho� � ha�e o�e�„f,�a,e of consent to se�f APPLICATIO�i FOR BUILDING PERMIT �
insure,or p cerfificote of Workers'Compensation Insuronce,
or a cerlified copy Ihereof(Sec 3900,Lpb.C.J
61WBMX75'Q�„ Hartford Group COUNTY OF LOS ANfaELES BUILDING AND SAFETY
Policy No. Pa�Y el11lDING
� Cerlified copy rs hereby furnished. �FOR APPLICRNT TO FILL IN ADDRE55 , W �'t 1 'ff Drive
OCerlified copy is filed with the munty bufiding inspeo gUllpiN�.v�00 S. Whitecl i ff Dri ve
tian deparlmenl. AD�RFSSy
oo+e 7-24-87 Applicant Rramalaa Calif_ aTv D.B. H1��5 z�P �ocnurv D.B. H1115
CERTIfICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOi NOw ON LOT CRO55 ST.
(This section need not be completed if}he permit is for one 11 ASSESSOR
hundred dollars($100)or less.) TRACT 42575 , s�ocK LOT NO. MAP BOOK PAGE PARCEL
. TEL. �g��� MAP (
I certify that in the performonce of the work for which this OwNER NO. — NO. I I� ��
permit is issued,I shall not employ any person in any manner 3151 Ai rway Ave., #N � 9�„� SPECIAL �
so as fo become subject to the Workers'Compensation Laws. ADDRE55 JL c. CONDITIONS Q
c�,r Costa Mesa z�r 92626 "
Data Applicont ANGNEERT�R Aram I�dS$2llldil No752- 64 DISTRICT GROUP TVPE FIRE PROCESSEDBV O
7TICE TO APPLICANT: If, after making this Certificate of
;�mptlon, you should become svb�ect to the Warkers' ` �j 3 CO � ZO�Er �
�ompensation provieions of 1ha labor Code,you must forth- qDDae55 3990 Westerly Pl ace #1�� V c�.• �I/�
wifh Comply wifh sUch provisipns ar fMis parmit 5hall be TEL. STATISTICAL CU1551FICA710N APT. CtlN00. CA
deemed revoked. CONTRACTOR � B No. � ..�--` �
LICENSED CONTRACTORS DECLARATION ���� 409610 «A55 NO. DWELL.UNITS
I hereby affirm that I am licansed under provisiona of Chapter 9 ADDRESS NO.
(commencing wirh Section 7000)of Division 3 of the Business and ��� SEWER MAP
Prafessions Code,ond my liCense Is In full farce and affect. ' GITY CLA55 B BK � VALIUATION
SQ.F '� N0.OF .N0.OF CHECK
License Number �09610 Lia Clpss B SIZE�— STORIES 2 �� FAMILIES 1 ONE
Date � DESCRIPiION OF WORK NEW � sA�UAT�
ca���e��o� 0/B � '
SFR A°0
� ❑I om exempf under Sea f ALTER �
��, B.BP.C.for thia reason PLAN 25 R , REPAIR ❑ � �����CaC�
�' �ate: U5E Of DEMOL ❑ - � ° ��y f�'
. E%ISTING BLbG.
,i Signatura � A�PRNTT Bramalea Cal if. No850-1001 FINAI �/ / r ;'� `' ° n ���
OWNER•BUILDER DECLARATION DATE '�� !� �"�e}
i I hereby offirm that I am exempt from tha Controctor's License � °�'�+ ���
law for the following reaaon(Secrion 7031.5, Business and ` ADDRESS 3151 Airwa Ave., #N COStd Mesa FINAL ;
� Profcsslons Goda). By �-�`p'Z-- s�>-� i ;i��i'�
� � BUILDWG
j 1, as ownar of the properry, or my employees with ADDRESS c���c:,.
� wages as their sole compensarlon,will do ihe work and ' L�c;[t, �7
i the strucWre is not intended or offared for sala(Settion IOCALI7Y
� 7044,Business and Profassions Code). MOV�NG TE�•
� � I,as owner of the property,om exclusively mn�racting CGNTRACTOR N�� '�1 1 �.C A
with licansed controUors to construU fhe project(Sec- ADDRESS
�ion 7044,Business and Professions Code�. y.o a m o o �
REQU�RED TOTAI SETBACK
CONSTRUC710N LENDING AGENCY SET BACK VARD HWY pROP.lME WiDThi
f I here6y affirm that there is a conslruction tending agency for FRONT � �7''J G�
' 1he performance of fhe work for which this pe�mil is issued P.L y ,^��;r�4v'4 v
(SeC.3097,CiV.C.). SIDE '"
i Toronto Dominion Bank '` o z 2°-�7
Lende�'s Name_ .� LDMA Re+.#
�" San Franci sco, Ca��1 . PC.Fee 5 rmii Fee �-� �
i .. Lendei s Address 10.5�
� 0 75.00
I<ertify Ihat I have read this application and sfafe ihat the Issuance Fee LDMA P/C N
above informofion is correct.I agree to comply with all Co�nty Investigo�ion Fee
io ordinances and State laws r lating to building consvuc�iaq Total Fee �7�� LDMA Perm.#
I m and hereby a��h rize r res n tives of this CouMy to e fer
upon 1 o e- entio eriy for inspectio purpo e� �`�
r < �7
� �O SEE REVERSE FOR EX7LANATORY LANGUAGE
� r ure of A p plicon�or A genf Dare
' .� ._...., _._.....
��..� - .,. ;�.� . : ;_ i .. _ .. . _ .._. ....... ._...'. ... ....... " 'i'"... '" ...._... _ .,_. ....._. .i...' _"_' ...... __. .......... ..'_"i..__ ..__ .... ...�
� '?�-'
� \ { E
t � � �
f `
��
/t�u � , „ � { � -I� r I .�•. ��.,+ -`j� �
Q,�;��" � _ i ;e, ,. � � , , � � r i �� � .. t. __ i , s, .� i ;
��� • �� �� � � ; , i t i ( i � f 3 ; t � , _ �� � � '
I I y � I � � f ; � €' � � � . I
�� � ;., � i , � . (; y 3 ; �, � � ,
�t�� � .a • � : � Ja " I ' - - � � � � � � i 'I :i � � . it i � �
�� � i � ; I �.� ` ' ( � j � I , J � i �, f , ( r'�, � �
; ( : � � . - � �
..,. . : .
�.. ,_._.
� . �
,.^., , ,..._..... . �... .........�..._.t....... .r -----� - ,_... r ... � � ; � I i '� ; � ;
\ `; . ;`��—. :... � ��� �.�.�Sa� `�,.- . , ; i � i . I I i : � ' � �; ; �.
, ..�._
��;�: i i {.'� .�. �- �� �... 1 ^t - ' E ( 8 �
i =
�
� � .�
� I \ � `'�L'+: �'`,S � t
� C' \ \. ; �� : , �--i. . � ... . . _. ..1.. .._.. _ .. _.�.._ _.. . _... . _ _�. .j.�
„� .; .—_i�.. �:�.,`�•��'�'"`; t ; ' ( � ; � ' -j. ;
.c�, i 3 ' !�, � � ., i .'.. ` .�, �:
� ;.- t _-• �.� �� I i � ;
� ! ; ec � °� V� � � � as - i �
�.
. , �l � �-'- - - �
.:.. , ......' "' . .....,�,. . ,. .._ .... . �
( �¢+ % � i � � j � i� �.. ,�' }�
..--� � ; , � , �
;�v � � � � � `" .... .r .._ . . .t_.........,.. � ....._�. p ...�..:._ ,, .. _ ...._ _ . ... w . :i � � I�:
� � t�� �. . .�.. �.. .' .�..
x5 ��� I � �� g .'. i � ...� ..i. `'...�.I �� I � � {^ :
R f�� � B � � ' ! � 7 : i., i ;�i
�
� ; ,
���. i ` '� P''" i 'y �
.�.
:� � ' � � � •d ha n ' , A .
:
, . p �
r '
;�� �f : � � � �� �. i ., .` .._. ..... - '-�.......�-.. ......__.. �............1 ._.. _ ....._j......... ..._... � . ;)Ra �
, . , ., , � � � '
. ; , ,
:
. ,
, , . 3 7
. .._� ;
, . , : � � . ;{ .,, � ` �_ � E„
.a
� . . . . . s : 1 { 1'
� � i �� i E � f
' ' ;. E
; �, , , . . „ , .. ' i ,� '
�
, . , � � ; , � < i ,
� ;
j : � ' : : � � � .. � , . {� ..... _...�r•',. ---.._ ..... [
. ........ ..�
� 1 I I � � 5 r -�
� � , , i (. I I � � L ` " 6 s
" , � j � 1 i .�, 1 a
, � � , � I ; i � I ( i I I � II � :7a � I , � 6
- I �. g§ i : : ' , . . e
i , � 1 j � i : i ; � �' � � ! �`f ` : { j ,� ra R � ' j� `..; � i
� ; � ; 3 i .� I i ` ( � ! � I I 'f �" �� z � ;i A :
� i' C..'k �! ;� {
.
�
� � � 3 � � $ € i � � � i � � ii m. .� t
� �
; ! j 1 ; ( 3 I
, ,
� , e :
�.........._ .......�.__.._..,.... .� .__..... . .__.._ .._ ... - --.- ..... _ ...._ ._ ' . �
� ...:.
; i ' i �_..._� i j i.. _f i'— --_ y_ - —_ - - � -- -- �- ._._ _ . _ ... ---. _ .i.._.__�. .f
: , �
' ; I� s 1 �I :
.:.. . .. ._,l _
: �
�_. � _�. �[ �j.. ,_ i j.. �l.
# ;
;
; ' . , 3 i ` . . ji _f. I. �..
� 3 � ;
; , . � ( ;
_r.i [. ;...� �..� .d�.. ...�
� � � i i (( � � ' � f � � S i �^� � � E I I � I � } � E
1 �3 { ' � ,i ' � � ' � � I � �
. � . � �.. � � } � i � � ; t j j E , ; .I i � ! ( � y
' g ! i � ; E ! [ � ' . .l � ' 1 4 � � { ( � � � I { � �
I � � i ; � � ( � ( � j ` ; � � � , ' �
. � I :` _ 1 � ' ' � ' ; i � I !E , ' I j � �
, € ' ' ! � ! : f + ' ! j � � ; I � ± � - i i ' � ; �
! I I i � ' I � � i i ! � I �i ' � ; 1 1
, ( � ! � ! ; � 3 ' - ' � � � � � � ! � I 3 ( �'
i i .. i i i � � .. . ') � � � i i k . - � �.�' 'i � � � ' i ��_�
� ; '_; ; , i j � ,r-.E
� � ; i � ; ' � - � , 3 , i � � _) ; '� .
i � � ' i � ! i i i i i � i ' i � i � � i � � ( �>::�
� I i , � ` ' I 1 ! . : f ; � � � . C i ' ; � :� j � '` ;
� � : i � � � :��
� � ' � i � i � I '( ! � � 1 ( ; � ' f ' ���g
� , ' ' ' ; j I ' I � _ ! ' i � k ' � � � :
, � ' � � � � � � � 1
' j � � ' i ; � a ; i j $ � I � 1 j ! j I � ` � ' I
; ! ; i � ; i ; ; ' . ; i j ; : j i � ( I . j ; �
; ; � 1 : � � E � � � j � ; j + ; ! , � ;
� ' ± � I ' i I � ! � � i � � ( � � � � � � 3 � i � I i � �
� ; p I kl ; � It ( , � � ; _ �
; I � ; � ` ! � { � � ! f , i ; ' i � � 1 ( f t �
� � � ) ' � ! � , i ( � � j . I � I 1 � � � � � i t
! . f � ' j � � � € . 'b ,� q _ ~.� $' . - -
: i i � ^ i' � y+ �. � :`
: � � � i � �' • ,s "' � , : ¢� �_,• �
� I � : � : � .. f _ �. � �.' -� 'q "` �;; �' : ;T , , ;� , �'
I � � � � k t � , �Y "� � . ' _' ,-�
� . ' . ; � � ( �` .. ' p� c' t .. K��
I � � i ,. • ;w n�i �- ,. , � z .�. �
4 I i ( i � � �� , , ^ ' ,.
i t . : , . � . t � .. .�. y. � . ,. .
i } �� f j I _ •• 'T _ ' . ^a - b 4.,, " �� ' .
� ' � � " '� `?. 5,,, .7 '_
� , � ... :3 . ' �Y
, � ' ' j � ^v� � .. h+. ' . . � .. �S _ .« ' ~u� ^S .. � .
1 ( . � 1 � i �,�� � k .i. > '�•3 3 S, -"§ .., `^� .� " _
i � . � I C � - � , � w._ ` ' _ , .. . J
; � i _. .. . ..
; . � ; �_ ; � �, �� � � ` � �� n
� � � 1 � � � t j i €cr.`� i I i` � �;. .- -. .._ �3 , o "' � . ' _ " Z k„
( . ! ? ` � � �}} � � . � � . ^ . ^ � `���`= :a. ... ...
i ' ' , i �a� i � �.y ' ; �? Y � �``~„ • � ..
� � � � � i ' I ��sF ' i i `� � ,.. ,. , ~9 ' ; :a 8 ' , .
t � ' , £ � " L ' 4':,, r" .
' � � �zr~ ,.4 .. b ..
� i ' � � . ; ; � � k � ., , � -, ' 't� �` ;;. ^ _ �" � `� � �� � � `a
� ;� ! � ; j ' 1 � c F . .. ,, � � , ,. N .
� t i ! � � ¢ g ( i • . � • „ -. ,. •�' r' ,. . .
; '! 4 j � � � i -=• j ; � � �, :,,.�.� . � ... .. . - . . . , � . .