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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 , � . 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