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HomeMy WebLinkAbout1195A 1196A _ WORKERS'COMPENSATION DECLARATION � ,/'� � I hereby affirm ihat I hove a certificate of conseM fo self qpp��CATION FQR �UILDING PERMIT � insure,or a certifimfe of Workers'Compensation Insurante. or a certified copy thereof(Sec.3800,Lab.C.� Pou�YNo.61WBMX75�,pnny Hartford Group LOUNTY OF LOS ANGELES BUILDING AND SAFET.Y � Certified copy is hereby fumished. FOR APPLICANT TO FILL IN Bu��D�rvG 90'� $. Whitecl iff Drive ADDRESS � Certified copy is filed with rhe county building inspeo BUILDING � tiondeparlmenL ADDRESS 902 S. Whitecliff Drive �ara ]-�Q-�Applicant �3ram�laa Calif_ aTr zia �ocnurv D.B. H711S CERT�FICn7E OF EXEMPT�ON FROM WORKERS' No.oF eio�s. NeqResi COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CRO55 57. (This seUion need nof be completed if ihe permif is for one TRACT 42575 .• s�ocK �OT NO. 12 ' ASSESSOR hundred dollars($100)or less.) MAP BOOK PAGE PARCEL TE�. USpp��ZONE MAP �/ I certify that in Ihe performante of the work far which ihis OWNER NO. - �+�a NO. a�Y""��� permit is issued,I sholl nof employ any person in ony monner qDDRESS 3151 Ai rway Ave., 1tN �� SPECIAI �� so as to become subject to the Workers'Compensation�aws. C,17 cqNoiilONS � c�rr Costa Mesa z�P 92626 U Date Applicant � ARCHITECT OR TEL. TICE TO APPLICANT: If, after makin this Certiiitate of • OISiRICT GROUP T7PE FIRE PROCESSED BY O 9 ENGINEER NO. '�mption, you should 6ecome subject to the Workers' 1� I CO T�ME � �ompensotion provisions of ihe Labor Code,you must forth- ADDRE55 3990 Westerly Place tt17� D� ��.-'� � � p.J with comply with soch provisions or this permit shall be TEt STATISTICAL C1A551FICATION � APT. CONDO, a deemed revoked. CONTRACTOR Q B rvo. �Zy Z LICENSE�CONTRACTORS DECLARATION ���� 40961D CLASS NO. DWEtL UNITS � I here6y affirm that I am licensed under provisians of Chapter 9 nDDRE55 NO. (commencing with Section 7000)of Division 3 of the Business and , ��� SEWER MAP Professions Code,and my license is in full force and effect. C�Tv Ctk55 B BK � VALIDATION 50.FT ' NO.OF NO.OF CHECK License Num6er 40961Q Lic.Class B SIZE G� ,• STORIES FAMILIES 1 ONE � VA�UATION DESCRIPTION OF WORN NEW �.p.g.p Contractor ��B Date ❑ s `+a.+�ftre✓ 5FR ADD �I am ezempl under Sec. _ ALTER � „ I 'I v��1 0.8P.C.for this reason REPAIR ❑ S �� � Date: uSE oF `�P�� 3� � a c a�� EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL FINAL ,/I r ���fa C> OWNER-BUILDERDECLARATION PRINT) Bramalea �d�l'F. N0.85�-10�1 DATE `'�`(+�/%}�� I hereby affirm that I am exampi from the Conrracror's License a e,.�,��U Z s, law for the following reoson(Section 7031.5, Business ond ADDRE55 151 Air a Ave. #N Costa Mes FINAL f Professions Code): PRE EN By ,�;,l.b,-ctt�,_ ��.'�€y��7 � BUILDING ' i, os owner of the proper�y, or my employees wi�h qDDRe55 wages as their sole compensation,will do the work and �OcnuTV ' the strucwre is not intended or offered for sale(Section 7044,Business ond Professions Code). MOVING TEL. � I,os owner pf the property,om exclosively cantracting CONTRACTOR NO. _"�_'� '� 9,p� wifh licensed mntractors to consfrucf Ihe project(Sec- qDDRE55 �o o e m o ? tion 7044,Business and Professions Code). CONSTRt1CTION LENDING AGENCY SETaBAC�K YARD Hwv TOTAPROP.�LCNE WiDiH � .`]���p I hereby affirm that there is a construction lending agenty for FRONT the performance of fhe work for which this permit is iss�ed P.L, � . e �r`��J`�_ ($eC.3097,Civ.C.). SIDE p . P.l. �ender's Name Toronto Domi n i on Bank U B.2 t�—8 7 5an f ranci sco, C.1�1 f. P� Fee E +=-Y"""�����mit Fee ��.� �DMA Re£.p Lender's Address ' � I tertify that I hova read this application and stafe thaf Ihe 75•�� Issuan<e Fee 10•50 LDMA P/C k a6ove information is correcf.I agrae to comply with all Counfy in�as��gat�on Fee ordinances and State laws relaling to building constroction, Tmal Fee '��.�0 and hereby authori e�ep se a�ves of this County fo enter t�roa aerm.# � upon the ob e- e tion r p ty for Inspecrio purp ses. � � �� 1 ^ SEE REVERSE WR E%PIANATORY LANGUAGE 'gn u e oi Applimnt or A Ie . ' , .� .__ 'i__'_"; .., a' "' }'= '_ . '"'_f'..... . .. .. ... _.... ._. _... _.. ... _ ... = _ .''' ' " ' . '__ ' _ _"_.. .y.__.� . �� � . . :�_; .. � ,.E ;. . � � .....� ` i ' ' n, r� .,I c`�w . , �.. ., i .: � _. ;j; ` , . - <t. �: � . .. _._ ..-- -�—� i� .. . i � . . : � ,. . i . , . � , ..i '.: ., ' . ` t r; �.� . � � � � i ; ' ; � ; € � � � ! ' i i, + �f � � . . �, i� ` � i . ! .. 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