HomeMy WebLinkAbout1185A 1186A WORKERS'COMPENSATION DECLARATION r� '
I inw�ebora{ce��fca'teofWorkersriCompensotonensuro�e" APPLICATION FOR BUILDING PERMIT �J
o�a certified copy Ihereof�Sec.3800,La6.C.) COUNTY OF LOS ANGELES BUIL�ING AND SAFETY
PolicyNo61WBMX75 �mPa�Y Hartford Group
� Certi£ied copy is hereby fur�ished. FOR APPLICANT TO FILL IN Bu��o�N�' 922 S. Whitecl iff Drive
ADDRES$
� Certified copy is filed with the county building insper BUILDING 92Z J�� Whitecl iff Drive
�ion deportmeni. ADDRESS
Dote 7-24-87 Applicont Bramalea Calif. ��rY D.B. Hi71s z�P �o�A��,Y D.B. Hills
CERTIfICA7E OF EXEMPTION fROM WORKERS' NO.OF BLDGS. NEP.REST
COMPENSATION INSURANCE 9ZE OF LOT NOW ON LOT CRO55 ST.
. (ihis section need not be mmpleted if ihe permit is for one ASSESSOR
� hundred dollors($100)ar less.) TRACT 42575 BLOCK LOT NO. 16 MAP BOOK PAGE PARCEL
, TE�� USE ZONE �P �/
�� I certify ihat in the performance of�he work far which this OWNER JJO. - Np -�'
j permil is issued,I shall not employ any person in ony manner 3151 Ai rway Ave., #N �Jf �� SPECIA� ��
� so as to become subjeU fo the Workers'Compensalian laws. .4DDRESS acy�jtl J CONDITIONS �
� �,TY Costa Mesa ��P 92626
I Date Applicanl ARCHITEQ OR TEL. �
I '�QTICE i0 APPLICANT: If, after making fhis Certiticole of ENGINEER Aram Ba n No. 752-1864 OISTRICI GROUP TVPE FIRE PROCESSED BY Q
' lemption, you should become subjecl to 1he Workers' .11 �� � (,~j
�.ompensation provisions of}he Labor Code,you must forlh- ADDRE55 3990 Westerly P1 ace it17� �� (l��j � �,, W�
wilh comply with such provisions or Ihis permit shall be TEL S7ATISTICAL cfA551FICATION APT. ONDO. fl!
� deemed revoked. CONTRACTOR ��B NO. � Z.
i LICENSED CONTRACTORS DECLARATION uC CLASS NO. OWELL.UNITS�
I h2reby a4firm thoi I om licensed under provisions of Chopfer 9 ADDRESS NO. SEVJER MAP
� (commencing wirh Sedion 7000)of Division 3 of ihe Business and ��C.
i Professions Code,and my license is in fuli force and effetl. ❑7Y CLASS B BK � VALIDATION
i SC�.FT. - �'NO.Of NO.Of CHECK -
� License Number 409610 �{�,Class B SIZE STORIES 2 FAMIlIES L ONE
� � VALUATION
� O/B DESCRIPT�ON OF WORK NEW ,y,n,p�.�b
; Contractor Dafe ADD � s'�'�V
! ❑I am exempt onde�$ec. ALTER � �� �� , ! I �::F�
PLAN 24 R �
B.EP.C.for Ihis reason 1 REPAIR � S � ,. o r�1
! USE OF ,
� Daie: E%ISTING BLDG. DEMOI
i � '�:> ��d7�
APPpRANT� Bramdled Calif. No, $50-1001 �/j-,-
� Signature FINAL
OWNER-BUILDER�ECLARATION DATE i b�d� y c(;j ;�'I J%�.
1 hereby offirm thol I am exempt from 1he Coniractor's License qODRE55 3151 Ai rwa Ave., #N C.OStd Mesa FINAL
Lpw for the following reason(Setlion 7031.5, Business ond �,..��
Professions Code): P BY �������✓
Oz;�
� � BUILDING
� I, os owner of ihe prope�ty, or my employees with ADDRESS
� wages as their sole compensation,wili do the work and
� ihe siructure is nat intended or offered for sale(Secrion IOU+LITY ' _,�I � �/����
; 7044,Business and Professions Code). MOViNG TEI.
CONTRAC70R NO. F'
I � I,as owner of 1he praperty,am exclusively contraciing ,� e o m • e (
j wilh licensed contraclors to conslrucl the project(Seo
i lion 7044,8usiness and P�ofessions Code). ADDRE55 � a J(��.O Q
REQUIRE� TOTAL SETBACK
� CONSTRUCTION LENDING AGENCY SE7 BACK YARD HWY PROP.LWE WI�7H � �,��; �1��t
I I hereby affirm ihat ihere is a construction lending agency for FRONT
the performance of the work for which}his permil is issued P.L �.
($BC.3097,Civ.C.). SIDE �'���� �
i Toronto Dominion Bank ``
Lender's Name
I � San Franci sco, Cal i f. P.C.Fee$ � Permit Fee �Gs� ��'�Ref.S
�I .. Lender's Address '
� � I cerlify thaf I have read ihis application and state Ihat the '� Issuance Fee lo•50 LDMA P/C k
a6ove information is correct.I agree�a comply with all Coumy Inves��gauon fee �)
i o,o Ordinpncei and St e lo s rela ing to building consirutlion, To�al Fea ��7�� LDMA Perm.#
and hereby auth ri a ra res nt tivas of this Cou ty to.enter .
i � upon�e b Mio o rty for inspectio pur oses�� , .
�i �'/ �J
-p $EE REVERSE FOR EX�tANATORY LANCUA6E
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