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HomeMy WebLinkAbout1167A 1168A + WORKERS'COMPENSATION�ECLARATION ��, I hereby offirm thot I have a cer�ificote o,consent l0 5e�f APPLICATION FOR BUILDING PERMIT �i insure,or a ceitifimte of Workers'Compensation Insuronce, � or a certified copy thereof($ec.3800,Lab.C.) � � acyNo. 61W6MX75�'�Q�pa�y Nartford Group COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. FOR APPLICANT TO Flll IN euuowG ADDRE55 906 S. Whitecliff Drive j ❑ CeHified copy is filed wifh the county building inspeo- BUILDING � tiondeparfinenf. ADDRE55 906 $. WhlteCliff DrlVe � Date 7-?4-87 Applicont Bramd�ed Calif. c�r� D.B. H7��S zia �p�q��7y D.B. H111S � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BL�GS. NE4RE5T COMPENSATION INSURANCE SizE OF LO7 NOw ON�OT CeOSS Si. � (This seclion need not be completed if the permit is for one TRACT 42575 ' ],3 ASSFSSOR � hundred dollars($100)or less.) BLOCK LOT NO. MqP BOOK PAGE PARCEL TEL US ZONE MAP i I certify ihal in Ihe performance of the�.vork for which ihis OWNER � f n�1cNo.850-1001 �,A'i` NO. � �'.� � permif is issued,I shall nol employ any persOn in pny manner qDDRE55 3151 Ai rway Ave., nN � T� SPECIAL � '� so as lo become subjecf to ihe Workers'Compensarlon Laws. [�DC� CONDITIONS � � c�r� Costa Mesa z,p 92626 � �afe Appliconf qRCHITECT OR TEL. DISTRICT GROl1P 7YPE FIRE PROCESSE�BV Q � OTICE TO APPLICANL• If. after makin �this Cerfificate of ; g ENGINEER Aram Bassenian No. 752-1864 ,.mption, you should bamme su6jeu to the Workers' CONST. Z 'r— I ..ompansation provisions of the Labor Code,you m�:�fo�rn- 399D Westerly Pl ace #1�� �� �� � '� � with cOm I with such rovisions or this ADDRE55 � py p permit shall be � deemed ravoked. TE�� STATISTICAI CL4SSIFICATION APT. ONDO. [i1 � CONTRACTOR O�B NO. t � Z I LICENSED CONTRACTORS DECLARATION ���, CLA55 NO. �"� DWELI.UNiTS �� � � I hereby affirm that I am titensed under provisions of Chapter 9 ADDRESS No. 409610 E (commencing wirh Seaion 7000)of Divis�on 3 of the Busineas and ��� B $EWER MAP s Professions Code,and my license is in full force and effect. Ciiv CLASS VALIDAiION Sq.FT NO.OF NO.Of CHECK BK. PG. � license Number 409610 Lic.Class Q SIZE C.l— STORIES Z FAMILIES Z ONE � VALUATION :-� �, ��� DESCRIP710N OF WORK NEW g � i Contrattor D�B Date qoo , ❑1 am exempt under Sec. SFR � , �� ` `° m 2� ' ALTER � /1 p J� � 8.&P.C,for fhis reason PLAN 23 R REPAIR � s /f 7 p�s V � a '"�'.�j,�7 � Dafe: EXIS T�iNG BLDG. DEMOL ❑ � s �„:j 5;.�'%-�, � s�9nm�re APPLICANT gramaled Cdlif. TE�850-1001 FINAI / / I OWNER-8L11LDER DECLARATION PRINT NO. pATE �'/✓/J�,Q ��'1��8 7 �! I hereby affirm ihai I am exempt from ihe Coniranar's Licanse qpDeE55 3151 Ai rwa Ave. #N Costa Mesa � Law for the following roason(Seaion 7031.5, Businass and y � FINAt 1r i ProfessionsCode): py ,y.Ka,z.L�...- �. � BUILpING I, as owner af tha property, or my employees with ADDRESS ; �� wages as their sole compensation,will do the work and =j � �B A . the srructure is not infended or oHe�ed for sale(Section LOCALITY I 7044,B�siness and Professions Code). MOviNG TEL. ' �m 6 8 o b 1 I, � I,os owner of ihe property,am exdusively wniraciing CON7RACTOR NO. ' e.�,�,7�� �, with licensed contrqctors to consh�ct the project(Sec- qDDRE55 � tion 7044,Business and Professions Code). � n 's:�i�.U Q u �� CONSTRUCTION LENDING AGENCY SET�BACK� Y/�RO HWV TOTAPROPAL�NEF WIDTH ' I hereby affirm tha7 there is a consvuction lending ogency for FRONT p g.2�W g� the performance of ihe work for which this permit is issued p.�. (Sec.3097,Crv.C.). SIDE Lender's Name ^J Toronto �ominion Bank `` Lender's Address San Franci sco, Cd�1 f. P.C.Fee$ / Permit Fee , � LDMA Ref.p I cerfify thnl 1 have read Ihis applicotion and sta�e tho�the 75•O� Issuance Fea lo•50 IDMq P/C 71 , obova informafion is correct.I agree ro mmply with all County Investigmian Fee ordinances and State laws relo�ing to building construction, Totol Fee ��7� LDMq perm.N and hereby au h ize re esent Y es of ihis Cooniy io enter upon i a6 v ention o for inspection orpos s. �� l � � �i SEE REVFRSE FOR EXPLANATORY LANGUAGE igna e o App icam or Agen� ate ... . ,. ... . . ' ' ' ' . . ...'" _' . ... . .... ..... .. _. .._ '___ " ' ... .. _ .... .._ . . _ . _ . . _" , 'F , .... _, _... � i. , �a� �,::;. . � �.. C� . � , I � . � V . :. � ii :�, - j �' - � a � + . - .. , t � ' ' 3� ?� � ' ' �` � � ,� 9-. _t _; I 1 � �V • � � - �.r ; � F . � % i _4 � } �� { ( i _. , .. ' .., ; r , ;� I � �, , ; I � � "' , c' F ;i � �� ` i,. � i ; � � ' i f � i � ; ' t! 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