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HomeMy WebLinkAbout1181A 1182A . WORKERS'COMPENSATION DECLARATION � , � he�aby o,f�,m ��af � ho�e a certificate of�o�5e��,o seif APPLICATION FOR BUILDING PERMIT insure,or a certificote of Workers'Compensation Insurance, or a certified copy thereof(Sec.3800,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo61WBMX75YQ�mPo�y Hartford Group � Buao�N� g01-�S. Whitecliff Drive � Cer�ified copy is hereby fumished. FOf���APPLICANT TQ FILI IN AD�RE55 � Certified copy is filed with the county building inspec- euIL�ING gol S. Whitecl iff Drive fion deparimeni. F+DDRE55 oo�e 7-24-87 Applicant Bramalea Cd�lf. arr D.B. Hills ziv iocnurv D.B. Hills CERTIfICATE OF EXEMPTION FROM WORKERS' NO.OF eL�GS. NEAREST COMPENSATION INSURANCE SiZE OF LOr NOw ON t0'f CROSS ST. (This section need not be complefed if Ihe permit is for one TRAGT 42575 BLOCK lOT NO. 1� - AMP BOOK PAGE PARCEL hundred dollars($100)or less.) $�,$ TE�. V,`Pf� MAP I terlify fhaf in the performance of ihe work for whith ihis OWNER O. �1 OZ NO. r '�- permii is issued,I shall not amploy any person in any manner 3151 Ai rway Ave., #N SPECIAL �y' so as to become subjetl to 1he Workers'Compenwtion Laws. ADDRESS � CONOI710NS p c�TY Costa Mesa z�P 92626 � Date Applicont ARCHITECT OR TE�� DIS7RICT GROUP NPE FIRE PROCESSED BY Q '9TICE TO APPLICANL If, after making this Certificate of ENGINEER No. -i� 64 CON ZOy�.., F"' iemption, you should become subject to ihe Workers' r� ,�7 �7 �- �U �ompensation provisions of ihe Labor Code,you must forih- AD�RE55 3990 Westerl y Pl ace #1�� p�-� � �V� � with COmply w'th such provisions or ihi5 permif shail ba TEL. STATISTICAL ClAS51FICATION APT. CONDO. UJ deemed ravoked. CONiRACTOR Q B NO. �, .�( Z LICENSED CONTRACTORS DECLARAT�ON LIC. CLASS NO. �WEIL.UNITS_Ll— I hereby offirm ihat I am licensed under provisions of Chapter 9 AD�RE55 NO. (commencing with Section 7000)of Division 3 of fhe Business and ��� R SEWER MAP Professions Code,and my license is in full force and effect. � UTY CLA53' BK � VAIIDATION � SQ.F. NO.OF NO.OF CHECK License Number 409610 u�.ciaSS B - s¢e G�— sroeies Z FAMILIES 1 oNe n VAll1ATION Conlractor �IB Dafe ' DESCR�PTtONOFSFRK ADD � s� �, �I am exempt under Sec. q�iER � ) �T 7 / `� i ! `� � F; .��.. B.SP.C.for this reason PLAN 24 REPAIR S /�a� /J� '� r �- �+(1 USE OF �. Date: DEMOL � E%ISTING BLDG � Signoture APPpRINN� Bramalea C(���f. Np. 8�J0-1��1 FINAL '/ � �� !r�v � OWNER-BUILDER DECLARATION DATE Y"�/!s�/,S',� � d-.� I I hereby affirm�hat I am exemp�from tbe Coniracror's License !i '` ' �� �`'' iLaw for�he following reason(Section 7031.5,Business ond �+DDRE55 3151 Airwa Ave., 7fN COSta Mesa p�ryp� � Pro fessions Co de): P R E E N 8 y �Li-t<.k.�. U i C�"� / � I, as owner of ihe propeny, or my employees with pDDRE55 � wages as iheir sale compensotion,will do the wo�k and �he StrucWre is not infended or offered for sale(Sectian LOCAIITY ' .�-! 1 �G� 7044,Business and Professions Code). - MOVING TE�� + � O1,d5 owner of Ihe properly,am exclosively tontracfing CONTRACTOR NO. .�.�w a u , o '� wlih licensed coMractors fo consiruct fhe proje[I(SBP tion 7044,Business and Professions Code). ADORE55 + ,�J(��(�� UI ED yqR� HWY TOTAL SETBACK CONSTRUCTION LENDING AGENCY SET BACK PROP.LiNE wiDiM � ,�la�f�,\�J"c I hareby afflrm thot there is a construction lending agency for FRONi ` �he parformanca of ihe work fOr which ihis permit is issued P.L, '7 (Sec.3097,Civ.C.). SIDE U"'T;��;"�`, Lender's Name Toronto Dominion Bank P`� �j� � ��JY;� IDMA Ref.N m San Francisco, Ca��f. P.C.Fae§ PermitFee ' lender's Address 1�.50 75.00 � � I certify�hat I have read this appiication and sfate lhat the luuance Pea IDMA P/C k � above informafion is torrect.I agree to comply with all County invasr�gotion Pea 'q ordinances and State Ip s rela ing 10 building construdion, Total Fee �o �• LDMA Parm,p R and hereby aut or e re es lives of fhis Counry to emer � �pon fhe a ve- tion rty for inspecfon pu poses. � � "'7 SEE REVERSE POR EXPLANATORY UNGUA6E �� ��,. ign rore oi App�kan�or Agent Oal � � � - -.. :. ....... �� ........._z_......,._..___......,'—"- . ...�.._ .. _ ... _._. ..... . ....... .r.. . ._'- . ..._..r,... _ .... _. . . _ , �1�;`�iC•_ .;. ....�,,, . � � . _ �A . ,. "- -...--" _ ' . : ...._ ...... __.. .. _;�-�—__.....--r_.�..„ �, ` .. � ; ` ' � �E i j ` I ,�.n.:y� ;C ;;'; ; o I r'2' ei. i - i , � ?�'� .. 4 .. ;, , I � ,: . ^. r„ : ' , ' `1 i ' - � i ,; ha.i� , .. . ,. �.� ,;; � .; ; �. 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