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
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