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
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