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HomeMy WebLinkAbout1183A 1184A WORKERS'COMPENSATION DECLARATION � Insu�eborpa4crertif�oteofwokersr�Compensation�lnsurancef APPLICATION FOR BUILDING PERMIT or o certi£�ed copy thereof(Sec.3800,Lab.C.) Po�;�YNo.61WBMX75�f}�,po�,. Hartford Group COUNTY OF LOS ANGELES BUILDING AND SAFETY � Ce�rified copy�s he�eby fiurnished. FOR APPLICANT TO FILL IN euuoiN� g10 S. Whiteci iff Dri ve ADDRESS ❑ Ceriified mpy is filed wilh ihe munty building inspeo- BUIIDING � tiondepartment. AODRESS 910 �S. Whitecliff Drive �a+e 7_94-R7 Appliwnt Rrama7ed Ca7if. c�rr D. . H711 ZiP iocnurv D.B. H1��5 CERTIFICA7E OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF lOT NUW ON LOT CROSS ST. � ,f ASSESSOR (This section need not be wmplated if Ihe permit is for one iRACT 42575 BLOCK LO7 NO. 14 hundred dollars($100)or less.) MAP BOOK PAGE PARCEL TEL. US ONE �+P I ce�tify�ha�in ihe performance of the work for which ihis OWNER � NO. — �� � �' ..���� permit is issued,I sholl not employ any person in ony manner 3151 A i rwa Ave., 1fN SPECIAL �� so as to become su6jecl to ihe Workers'Compensation Laws. A�ORESS y Qv$c� CONDITIONS �y cirr Costa Mesa zia 92626 � Date Applicant IIC 'OTICE TO APPLICANL If, affer making this Certificate of ARCHITECTOR TE�� DISiRICT GROUP TYaE FIRE PROCESSED BV (,a ENGINEER � NO. 2— 6 �emption, you shouid becoma su6iect la ihe Workers' J� CON15L 7,pWE f� �ompensation provisions of the Lobo�Code,you must 4orih- ADDRESS 3990 Westerly Pl ace �1�Q �(� /\„'3 �� � � W with comply wilh such provisions ar this permit sholl be TEL A' deemed revoked. STATISTiCAL CU�SS�FICATION FlPT. ONDO. (,� CONTRACTOR O B NO. �, IICENSED CONTRACTORS DECLARATION �i�, C�a55 NO. � oweLL.Uwrs�/ I hereby affirm thot I am licensed under provisions of Chapfer 9 A�DRE55 NO. (commencing wilh Section 7000)of Division 3 of the Business and ��� SEWER MAP Professions Code,ond my license is in full force and effect. �� CITY - � CLASS B YAIIDATION �� SQ.FT '� NO.OF NO.OF CHECK BK. PG. p SIZE — STORIES �Z FAMILIES 1 ONE � License N�mber 4�q�]�n Lic.Ciass_t� VALUATION I� DESCRIPTION OF WORK NEW �ppq Coniroclor ,v.�R Date ADD a �V , : � �� s?�i'�., �I am exempt under Set. SFR � � ALTER _ ��� , 6.8P.C.for this reason S }�d a M .�� REPAIR . Date: . K ST�iNG 6LDG. DEMOL i ���J I rJ . Signature APPpRIANTj Bramalea Cal if., No.850-1001 FINAL � , v,:,;J=,��;;; OWNER-BUILDER DECLARATION DATE f����,� I hereby affirm Ihat I om exempl from ihe CoMractor's License - qpDRESS 3151 Ai rwa Ave. #N Costa Mesa � ��C 8"�.�'i � Low tor the following reason(Section 7031.5, 8usiness and FINAL Professions Code): :� PRE ENT By <'-e-`�"� � � BUIIDING I, as ownef of the property, or my employees with ADDRE55 wages as iheir sole compenwtion,will do the work ond F 1he siructure iz not iMended o�offered for sale(Secfion LOCAUTY , .`-''I 1 �.�l l� : 7044,Bosiness and Profession:Code). nnovwG ie�. . 3 � I,os owner of the property,om exclusively toniracting CONTkACTOR NO. �m o n o e � wilh licensed coniroctors to consfruct�he projeco(Sec- � a 0 t� ?.�� � tion 7044,Business and Professions Code). AD�RESS � REQUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY SET OACK YARD HWY pROP.LINE WIDTH �� ^�(j Li(,�j(,,,'u � i hereby affirm ihal there is a consiruclion lending agency for FRONT . ihe performance of the work for which ihis permit is issued P.L �j Z���_.&'� � (Sec.3097,Civ.C.). Pi�E � Lender'sName Toronto Dominion Bank An.y,�.� V.0 Fee$ �1 Permit fee ���l� �DMA Ref,$ , m Lender'sAddress San Francisco, �d�lf. , � I certify that I have reod this applicalion and slate ihat tha '�� Issuonce Fee 10•50 L�MA P/C k ° a6ove informafion is correct.I ogrea to comply wifh all Counly Imesnga�ion Fee 8 ordinances a d Stcte aws r I ing fo building conatruction, Tofol Fea � � �. tDMA rerm.M � and hereb a t orize pre tives of�his County to enter _ ,� upon t e ov me li er�y for inspec�'on pur osea. i � SEE REYERSE FOX EXPtANATORY LANGUAGE ��' ign re o+Applicant or Agent �o�a ' �--. ....... .. ..................__. � � . : i .._:. .... Z..r. _.. ., p.. ... ...__ _ ... ... . _.. � . i . :. 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