HomeMy WebLinkAbout1165A 1166A WORKERS'COMPENSATION DECLARATION �
� he,eeY aff„m thot I hove o cenifim�e o,�on5e�,fo 5a�f APPLICATION FOR BUILDING PERMIT
. insure,or o certiflcate of Workeri Compensation Insurance,
o�a certified copy rhe�eof(Sec.3800,lab.C) COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
PolicyNo.61WBMX7�J�@�Pa�Y Hartford Group
❑ Ce�riRed mpy is hereby fornished. FOR APPLICANT TO FILL W eu��oWG
ADDRESS 915 5. Whitecliff Drive
❑ Certified copy�s filed with ihe county building inspeo- euaDING g15 S. Whi tecl i ff Dri ve
fion deportment. ADDRESS
oare 7�4-87 ApplicaM Bramalea Cdlif. arr D.B. Hills ziP LOCALITY D.B. H111s
CERTIPICATE OP EXEMPTION FROM WORKERS' NO.OF a�DGS. NEAREST
COMPENSATION INSURANCE Si2E OF LOT NOW ON l07 CROSS 57.
(This section nead nat be completed if the permif is for one iRACT 42575 $ � ASSESSOR
hundred dollars($100)or 1e55.) BLOCK LOT NO. ,�" MqP BOOK PAGE PARCEI
O'NNER 1' n .No.850-1001 US ONF 1�P �/
1 certity that in rhe performance of the work for which this �t ��� NO. f "•3 T
permit is issued,I shall nOt employ ony person In any manner 3151 Ai rway Ave.� ttN SPECIAL ��
so as to become su6ject to the Workers'Compensation Laws. � AD�RESS �,OC.��1U CONDITIONS p
c�Tr Costa Mesa Z�P 92626 �
Dore Applicant �
-'OTICE TO APPI.ICANL• If, ofier makin Ihis Cerlificate of ARCHITECT OR TEi� OISTRICT GROUP TYPE FIRE PROCESSED BY tJ
9 ENGINEER Ar d$ enian No.752-1864 CONS. ZON F"
emptian, you should become subject tu the Workers' U
�ompensm�o�pro��slons of rha Labor Coda,yoo r„�sf forrh- qooaess 3990 Westeriy P1 ace #1�0 JJ Q�-.3 � W
with comply with such provisions or this permit shdll be , �
deemed revoked. TE�� STATISTIGAL CLASSIFICATiON APT. CONDO. V)
CONTRACTOR NO. �(,./ �
LICENSED CONTRACTORS DECLARATION ���� 409610 C�ASS NO. � DWELL.UN�TS�!
I hereby affirm fhat I om licensed onder provisions of Chopter 9 ADDRE55 NO.
(commencing with Section 7000)of Oivision 3 of ihe Business and ��� B SEWER MAP
Profeszions Code,and my license is in full force and effect. CITY /' . CLA55 VAU�ATION
SQ.FT. O.OF NO.Of CHECK
BK. PG.
Li[ense Number 409610 Lic.Closs B SIZE _ �STORIES z FAMILIES 1 ONE
! NEW �i YAtUATION �-�! ? ci.J A
� Controctor OIB pa�y +.' DESCRIPTION OF WORK s „y,Aq,,,,ryah
� �I am exemp�under Sec.
sFR n�� p �a-r�7av ;� . . �> e c 1
� PLAN 2 ALTER ❑ I�7 Q�� \ I �,,�;r�8.9?
! 8.8P.C.4or this reason REPAIR � s I1 7�;J(fl L� i��. J cs,�
Date: USE OF = �,',(j ,
! EXISTING BLDG. DEMOL ❑
� Si noture APPLICANT 7EL. . � �_
9 PRINT Bramal ea Cal i f. No.850-1001 FINAI �����. ?8���7
' OWNER-BUItDER DECLARATION �ATE
{ I hereby offirm ihat I am exempt from the Controcior's license qDDRESS 3151 Ai rwa AVQ.� #N Costa Mesa
Law for the followinq reason(Sectian 7031.5, Business and FINAL �
Professions Code): By ,��-e.-i'
� BUiLOING
d, � I, as owner of 1he property, or my employees with qoDRE55 "� � � ��A
i J" wages as iheir sole compensafion,will do ihe work ond
� the strocture is nol inlended ar offered for sole(Section � ���A��T� , ;;a . e s o �
7044,9usiness and Professians Code). MOVING TEI.
❑ I,as owner of ihe property,om axclusively coMracting CONTRaCTOR NO. + ,�5�"�.O�
� with licensed contractors to mnstrucf iha projecl(Seo- ' qDDRE55 � ` (�,�� _
tion 7044,6usiness ond Professions Code). ^ > ].i;�;�
REQUIRE� TO AL 5 T
1 CONS7RUCTION LENDING AGENCY SET BAGK �ARD HWY PROR IiNE WI�TH
1 I hereby affirm that ihere is a consrruction lending agency for PRONT
� ihe parformonce of the work for whith this permit is issued - P.l, �a 7�,_���
} (Sac.3097,Civ.C.). SIDE
' Toronto Dominion Bank �'`'
i tander's Name
LDMA Ref.fl
� Lendar's Address $dtl Franc i sco, Cal i f. P.G Fee S � � Vermit Fee '
� � I cerlif that I have read this a lication and stata that the �J.00 1�.5�
Y PP Iseuonce Fee LDMA P/C N
above informa�ion is correcr.I ogree to comply wi�h all County Invesiigotion Fea
� � ordinancas and State lawe relating to 6uilding construction, ioml Fee .� Irt� LDMA Pe�m.M
! H and here6y a thori e rapresaniativas of this CouMy to emer
� � upon ih a e-m ti ne oparfy for inspecti n pur asas.
� SEE REVERSE fOR EXPLANATORY IANGUAGE ��
i Signa�ure of ApplicaN or Agenl Do1
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