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HomeMy WebLinkAbout1193A 1194A 1197A WORKERS'COMPENSATION DECLARATION � I hereby affirm tFaf� have a mrtificate of consent to self APPLICATION FOR BUILDING PERMIT insure,or a certifimte of Workers'Compensatian Insurance, � o�a certifed copy the�eof(Sec.3800,tab.C.) COUNTY OF LOS ANGELES BUILDING AND SAPETY a�cyNo._���ipony J�rtfnrd frnun Certi4ied copy is hereby furnished. FOR APPLICANT TO FILI IN BUILDWG ADDRESS 907 S. Whitecliff Drive � Certified copy is filed with the county building��sPe�- e���o�Nc 907 S. Whitecl iff Drive tion deparfinenl. ADDRE55 oare 7-24'8� Applimnt Bramalea Cd�1f. arr D.B. H1115 ziP �o�A�iT� D.B. H7115 CERTIFICAIE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOw ON LOT CROSS ST. (This sec�ion need not be completed if the permit is for one 42575 9 .455ESSOR hundred dollars($100)or less.) TRACT � BLOCK LOT NO. MqP BOOK PAGE PARCEL O`NNER Bramalea Calif. Incao. 850-1001 us QNE �P .( I certify thal in 1he performance of ihe work for which this .t]l, N�' j`Y" r permit is issued,I shall not employ any person in any manner ADDRE55 QCd G7 CONDITIONS � so as to become su6jeU to the Workers'Compensation Lows. � c,T,. Costa Mesa Z„ 92626 Date Applitanf � -'OTICE i0 APPLICANT: If, pfter moking�his Certificate af E+RCHITECT OR TEL. DISTRICT GROUP rypE FIRE PROCESSED BY d �empfion, you should 6ecome subject to �ha Workars' ENGiNEER Aram Bassenian No.752-1864 ST.� Z U �ompensolion provisions of the La6or Code,you musl forth- ADDRE55 3990 Westerly Pl ace #17� �V �,.,,��j �nJ � � �W with aomply with such pravisions or ihis permit shall ba � deemed revoked. TE�� STATISTICAL CtA551FICA'f10N APT. NDO. U) CONTRACTOR �IB NO. � Z LICENSED CONTRACTORS DECLARATION ���. C1A55 NO. DWELL.UNITS� � I hereby affirm that I om litensed under provisions of Chapter 9 ADORp55 No. 409610 (tommencing with Section 7000)of Division 3 of the 8usiness and L�C. SEWER MAG Professions Code,and my licansa is in full forte and effecl. CITY CLn55 B BK � VAtIDAT10N 409610 B SIZEF�� 5 ORI�ES 2 F MIL�IES 1 CO EK License Number Lic.Class � YALUATION ConlraCtor ��B Dq}e DESCRIPTIDN OSFR�K q p � S 1� ❑I om axempt under Sec. � , .-. I � �r�f� ALTER f 8.&P.C.for this rooson PLAN 26 i' REPAIR ❑ s / 7�/'�QQ , x a u�1 Date: USE OF DEMOL EXISTING 6LDG. � �� u ,x�,(��,C�;5 s�9�OfUfe APP��CANT Bramalea Cal if. TE� 850-1001 PINAt OWNER-BU4DER pECLARATIpN PRiNT N0. DATE � �,� ' ',<;�S`._'S'�� I here6y affirm Iha�1 am ezampt from the Contratio�'c Licensa (�'��� - ADORE55 3151 Airway Ave., #N Costa Mesa FINAI� , ;r p�.� law for the fallowing reaaon(Sadion 7031.5, Busineas and (.`[ ��7 Profosslons Cada): ' 8Y �,�ee�-� � I, as ownar of tha property, or my employaes with ADDRESS wages as thair sole compensotion,will do tha work and , �ha strunure is not intended or offared for sala(Saction �OCALITY 70d4,6usiness ond Profe6sions Code). MOVING TEL. � I,as ownar of fha property,pm azclusively conlrncting CONTRACTOR NO. _y� � �,(i� with Ilcensed coniraciors to construct ihe project(Seo- . tion 7044,Business ond Professions Code). ADDRE55 #r 6 m a a e � RE�UIRED TOTAL SETBACK F CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.UNE WIDTH I a�]�i Q,�j O I hereby affirm tha�there is a construction lending agency for FRONT ' ihe performance of ihe work for whith ihis permil is issuad G.L. ` �, y/;�� �;V,,a� (Sec.3097,Civ.C.). SIDE v.�. . Lender's Name '[gy^nn�+�n�Oq�lp�,��a,pf( C iS'c}�5—�% San Francisco, C(7��f. P.CFeeE �yS�B• �m�fFee �"D7S L°"'�Re`" lender's Address r _7 I certify tha�I have read ihis application and sta�e thai the 75•o� issuance F�e lo•50 �pN,q p��p , = � 1 �+ Fl e above informa�ion is mrrect.i agree lo comply with all Counry Imest�gmion Fee � � .y� i ' ' I 0� Q ordinances ond Stote laws relating to building construction, iatol Fee ���0� LDMA Perm.N c x . and her y ao horiz rep ntatives of ihis County to enter � ° e ( (!,.,„�c upo h b v -men o operfy for inspecti n pur'oses. .� ` +� ✓ /1 c� {� �1 �� SEE REYERSE FOR EXPL0.NAiORY LANGUAGE � �12,U�i,`,�(� ! '�� Sig atur af Appliconl or Aga�� � ' ' ' , ...,.__._... .._..... ... --- --- - -- - — --. s. . ._.... - -- -- -._ ... . ... _.. _.. .. . -- - � r'-. . . ..�.. .� � . f ` ! 3 � .� � r ' -. � � ' � � . , , __ ... _ `v ., I ' � �'- i € G , , _ ( i'4G � ';� ` � I� � � �_ 1�n � .. ' � ^ _ � � }• � - � ; � ' ! ' m j C: � , ., . ' �[ � � . � � �+ �_, � - �` i . 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