HomeMy WebLinkAbout1157A 1158A i ;
WORKERS'COMPENSATION DECLARATION /
I I hereby offirm ,ha, � ha�e a mrlificale of�o�5e�f�o=e�f APPLICATION FOR BUILDING PERMIT '
II insure,ar a certificote of Workers'Compensation Insurance,
I or a cenif�ed copy theraof(Sea 3800,tab.C.) COUNTV OF LOS ANGELES BUILDING AND SAFETY
PolicyNo61WBMX7 Q'�mPa�y Hartford Group
� Certified mpy is hereby fumished. FOR APPLICANT TO FILL IN BUILDING
ADDRES$
� � Cerfified copy i5 filed with fhe coUnty 6uilding insper BUIL�ING �
�iondeportment. a�oRe55 916 $'. Wh1teC17ff Dt^1Ve
I
oo�e 7-24-87 nPPr�o�, Rramalea Calif. c�Tv D. ziP iocAutr D.B. Hills
I, CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
� COMPENSATION INSUP,ANCE Si2E OF LOT Now ON LOi CRO55 S7.
� (This sec�ion need no�be compleied if ihe permit is for one TRAQ 2575� BLOCK �Oi n10. 15 � Y '455ESSOR
4 hundred dollars($100)or less.) /saP BOOK PAGE anece�
TEL. �q,,�� ,.!
I certify fhol in 1he pertormance of ihe work for which this OWNER Bramalea Cal if. Tn .No.85D-1 �Jdfi�E NpP �� ��7
permit is issued,i shall not employ any person in any monner 3151 Ai rway Ave.� '�N �7�7 SPECIAL �
so os to become subiect to ihe Workers'Compensation Laws. ADDRE55 ac{�(��r� CONDITIONS ry
c�rv Costa Mesa Z,P 92626 �
Date Applicant �
' TICE TO APPUCANT: If, ofter makin fhis Cerfificate af P.RCHITECT OR TEL DISTRIC7 GROUP TYPE FIRE PROCESSED 8Y O
� � g ENGINEER Aram Bassenian No.752-1864 ��� � U
i �mption, you should become subjec� to the Workers' ��
� �ompensation provisions of the Labor Code,you must{orth- qD�RESS �� d�
� with tomply with such provisions or Ihis permit shall be LL
deemed revoked. TE�� S7ATISTICAL QASSIFICATION APT. -CONDO. (!)
CONTRAQOR O�B NO. _1.f �
LICENSED CONTRACTORS DECLARATION i��, CLASS NO. �� DWELL.UNiTS -� � �
� I hereby affirm�hot I am litensed under provisions of Chapter 9 aD�RE55 n10.
� (commencing with Section 7D00)of Division 3 of the Business and ��� SEWER MAP
� Professions Code,and my Ilcense is in full force and affecL CITY CLP,55 B eK � VALIDATION
� 5�.F �NO.OF ' NO Of CHECK
License Number 409610 lit,Class B SIZE�- STORIES 2 r FAMIUES 1 ONE
� � VAWAT�
Contracmr ��B Date DESCRIPTION OF WORK NEW s
SFR ADD ❑ t
�f ❑I am exempt undar Sec. ALTER �
` B.&P.C.for this reoson PLAN 25 R � REPA,R ❑ S �`��� (J :j ; `a.7 A
�ate: USE OF DEMOL
jE E%ISTING BIDG. �
i Signatura APPPRANTT Brama1ea Cdl if. No 850-1001 7 � ° , � »2�
FINAL
OWNER-BUIIDER DECIARATION . DATE � /I
� I hereby affirm that I am exempt from the Contractar's Licanse ADDRESS 3151 A i rway Ave., #N Costa Mesa p�Np� x� r a�� J� 5
Law for fhe following reason(Saction 7037.5, Business and
P ak� I .).(J<t
Professions Codo)� 8Y .]�.�,,ti�.,-
BUILDING
� � I, as owner of the property, ar my employeas with ADDRE55 �j�;;��c«.s�
� woges as iheir sole compensation,will da ihe work and '
tha strocture is not intended or offarad for sale(Section tOCAIITv
7044,Business and Professions Code). MOVING TEL.
� I,os owner of the property,om exclusively confracfing GONTRACTOR ND.
with Ilcensed contractors to tonstruct the project(Sao- qDoaEss '=1 1 5,E F�
tion 7044,Business and Professions Code).
CONSTRUCTION IENDING AGENCY SEQBAdc �ARD HWv T�TApROP.LINE WiDiH F{ e o e e e �
I hereby affirm thot there is o mnstruction lending agency for FRONT � � a 7 0.`:.b 0
the performance of Ihe work for which Ihis permit is issued P.L.
� (Sec.3097,Civ.C.). SIDE T
� Toronto Dominion Bank P` 0 7��5��U
� lender's Nome
I m � . �..3 .�.y� LDMA Ref.M ; �t�$�C H`�7
Lender's Address San Franci sco, Cd�1 f. P.0 Fee 8 , ��mir Fee
I o I cenify tha�I have read�his applicmion and s�ate that the �5.�� ,ss�a e Faa 10.50 LDNJ+P/C M ,
� � above information is wrrect.1 agree to comply with all Coumy in�asf�gm�ao Fee
� o ordinonces and Si e law relati to boilding construction, iarol Fee �'�7�-� �oMA Perm.p
� h and hereb aut on e re se at ves of this Cou ty to enfer
� a upon he ov mion r p ty for inspectio pur ses.
I ` SFE REVERSE FOR EXPLANAiORY LANGUAGE �
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