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 � � �
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