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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 , ... ... __.. _.. .._. ..._ - — -- -- —._ _.. . .._....,.. � ; �. �.f. �._ .__,... €.. � i ��� i �: f ��- �� ; .. . � � � i r.` 4 . , - - -' ' - ' -' .- � . .. _. __ ' „ � .. , ; . , . < ' �.. . _ _ _ ' . ,� �.i ; t . ! �i ^ ! , ^ '' � " •- -A.-. [ _ . ' , . I � ' � t �( i � ! ..�� '�` � ' i ry ,� . i ' ,I a, f , v i . � H. , � iI � I � ! n ' � � - � t x i � � ' . 4 ;� � n �`� : � � � y � 1 , ' I , _ ' ; i i I �. S.� � i. � I = � � I ° ` � It ''• ( '�'• �..q\�. !� I� I " 1 1( ., � j ' t i . � � E . i � % ( � . � ��L}` ' � ' '1 " � , .. � . I ! , ( � ( � . �' Q t � ��:YV f � j ! ; : , � � � � . .. ' � � � i ' � ; � , + ' ; .n fp , ' i .... ._,.�ti._�_._... __....:..........a_...__ __ a.._.....p .. � , fi d � i _...�._. � � M �r�^— E ' ` • ��� � �. 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