Loading...
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 Si n r of Applicanl 1 Date i 1 _. _ _ . _. . . _ _ _ _ ; � , rt.... ,. ��, � .._ _... ., . _ , , � -- ,. � � _� - ; � , a �� � . . ..: ,. -� .. ,�;. ,. � .,. � _ _ ; . ' ,. �' -, , •: `s � � . . .: . .. �. � . .. .. . . .., , _ . , , _ ; ' t {; �+ ; , : � � . �.. .,. „ . _; � , - :. - � � ' _ ' " ...._ .... '-- � �`', � , .; . �- j ... � , " � � � i; ;-- -.¢._..._.._�. 3 � „ �.. . .. . � ( - � ' ,. � � � .. � < �v' � ,1� - � � — ., . . �� ..'. ` f � �: � � ;i � � f i � i � � `'I �C�� i= .; i 'j - [ s i� „�,�„ � i { - . 4 - - ; - J �� _'a i �� i I ,�`�'y:V�• . !J� I i � { � i - := . f :i i � v. � ; . ` �r i i ' � ` � � ` � . ;_i ... � I � ,� i � � w ;t ` `j , � ! � ; � ;� E :s � : . ,� i � � �'�.'; 1 �- ; , : , , . < � i i � � I }� � . _ ,., , , , � , � , , , . , , , , { ; ( ( <. - : .... ..'_�...,.: _.._:.._..�__..............�--•• - -._ ' .... .{ ,._. , ti� i - i � � � � � � i � ! ! � i '�( � € � � � : ; � ' _�.a �.... � � ;I /�, � �. s — i � ,-._. : i� .. . r C'.� , ; —'-'-- i C � .,_ � , 4 � : - :" C, . � t r.'r { , �, i`� �:\^�. ; _., � � � i i , � ; i �� . , ; t . � ; j 1 ; E . _�..�... � � 4. � �� � !t c:ry �."""' ... .' "'"' .."_........_; . ....."". ""' ' 'I . . .. .., ' _'.i... ..._..._.y--._�.;I....._�. ._.._ �� � �.�1. : : : ; .�.. ��}J ! � ��,'s �,y� .. � � _i _i. .�_ j Ji �'t... ' a 3 , M � ; � � �, ,�. — � "� �� . :a li i � ;� . i .. , , , � _.. ..._ _ 'c� , 'J � . ,.............._.�..�..___,�......._�.f_._,_.,.._... '...--i ---�..:� - - - - -- i " i ;s= i +_ ...s.. , � . . . ..1±....� ! . '� „ I � ° � � ? I ;� � � � I � �; � r ' ] �- _ � __.._.. ...._..�_..._ _........ ._.__ _ ...._._ .� . . _.. _ ... � � p_. ..� � i i �'a � ..( � '��K�'�, : �� � ,�i.: �,(T.� �� � � r j , � j � �i f � ; �) ( � rs 1 � , ; � `" r ; i �' �` ;A �� A, �- � � � � I , 'i'� "` � ` � � � . , ! 1 �. . � � , ' f � � �{ !�0 i� ': � i� --- '-- -- .. . _..v_.1 _ .... ._ , a —'- -'-- -' � ��-d a. a i �; I i � � , � ,. � � ,- --�-_ ;. �.. .�� E : i \� I ( i i� ,� I \), , �� ,� � �� �{ � ? I q „ ' �f � € �� � { � i : 1 i � { '�� � � .n 3 r � ' ' i 1 � �: fj ; . __ F .. -,k`--�- -._._� . { �. I � � i� �: � � 'I ( � i i � � ,i � � � ' '� � ' � � ° � I il � I: � i � � � � � '' � � � ` t � � � � " � i j ; j � j , � k � f ; € ; � ; �� � ;; ; � � { 1 � � ( � ! k ! ' � I � i { s: _. � 1 ' E[� 1 ; ' � ' ! 4 ? i !1 � � k � � i j i � I �� �..� � ' � i` � � . 1 � i I � � I I j , : .y � j 1 i � � ; j � ( � I �I � � v : _. , _ a.,___r . .r. _ . _ :_ i f�_-- ---��- ��___.,� �� �,_. - ' - _;-I - '- ---� - - � _ i a i � � �t_ � .j � � I a I I ;. ' � i � i !_ t : r ; � ; ' i � , i ; � � � � I I ' � : � ' j ; � � � j .. � ; - l � j I i I �{ � �I � I ( ; I I i � i ; � , 7 , � , � � ' �� ' � � � ; I i i I I ` � ' ' � . � � � 5 � j , � i j$` � , ' i: � . ; � i I ' � � � ' � � � I I � � = i e � , k � � � I 7 � ' I ! I � � � � � � � � � s ` � � I I � f ' � � ( � � � , � � � ` i � � j � . � � i i � : ' .. ;; i: i ; j i . � I �p� i i � � � � � . � � i ; ; � ; .. . ; � ��,� , , � j , ' E � � � � , � � , � � G �, � f , � I #�� , , � � ' i ` ! � ' , I � j ; � � i � I 4� , ; i j ; ! ' ' ; ' ' i ; ' j � i i ; . F �� i ' � � � I ! � i 1 � .. I � �. ; � ' j , : ; ; � . � . � � ��,f ! l i i : �' � � ' . : � i �...:3 : � , i � , ; : . � ' � j � , i . � i : I ' � � j i i I € f � � , i I �' . ! ! I� i �� t � � � ± � . ' � t �t"'� � I : ; ' i ( ? ( _ � ' � I � ' ' I 4� E � � � � i ; � : ! ; � � ' ( j ; � � . i ,I I ; ; � �. .i ' ' I � 6 � � ; ) � ( , i � i � i ' � � , ; � I i € � ; j ' ; . � ' ; � � ; � ; i ; ; ! I I � ; � i i i ! � ; ` I I � � � ' ; i � i � i � € � I ! j I � , � i i ' � � � � j : ; ; ; I ( � F � G • ; i f ; j I i � � � ; ; ; � ' ; � � i � ' i ` � j ( � � � � � � � � , � I � i i i � ± � { � ( � . . . � . . t � ! � . � � ( ( . ! � � . , ! � € i . � i . � f � j f i � ' I C: ' r ` .�: < ;�. :" ; m � 3 � i � ^� �' � c .. . � ; i : � : 3 ,� < '..:m '�� x . _ ';�. "� m _ i � i � I i i ± � g � ., h..:t ..� s ..�.,,_`� y r� j , I � { � � k g{ i i� `:, ' _ � ., . ,r � .. , (µ .. � '+ _ ._ j � — r c� ��,,rv -- ( 3 . ,. . :� ; � � � :: :, ;; � � : � � ' . � � I ` � { ` � :l ^ � �:...�; "M1"'"' '„"i`, :� y , e ,., . I i . S � � ... �`'... - 7. . .. �� . , .,,,` � � i � . I � , _. . . 'Y �: . � ' 'I i � 4 , � "�•>5 y - ' � � � .�; ( ; �i. ! � � i - � �.. _ ;� � r _ �C ... ry � n .. - s . ; j a ;,f � . ,� m � _ �: � � =�. � ,. � .. � i �� ; ; . - � �. , I � j i �5� , � � Y � ... .� w ,s .. ., I � n �. - , �; 1�� - . � j 1 1 I < ., �s s� � � i' � � i ` i i i j i :� � .,. z. w' ;� �; ;; . .• � . . i j � j �:�;� � �, � � i.. . ^ ;: .: ' '` � �' �:� � ' � � � � � �� � ��� � � � �'�' n � .. � � � � I � E ��q � i -. . � ; _ ' ^ „� .. .w. � �I � ( I },�`� � �. ' .. t'. -,� s_ f, �,� — 7.. � i i i 1 i ! � ! r - -_ ' ' . �a - - � � ., , � a ! . � � I � � � ~i �. , ,� .: . '� ¢, s...� �',r. -;o �- i ° j ' i I ` � � � z� .. .. . .. � 'c • , `- _ . � • r i ; f < < � �^ �3 '., �,� .. ,.. _ �; � , ;y , [ i 'Y _ _ � j � � � ' � ( ( � i I I ' . ,': _ ., , - ,, {; , � i � 1 � � , , _ � 1 i i i*+. � ( - ;<, !��-l7� . _ ;) i � ; � ` i � � � E , . .. .. ,. ' - .. � . . . ., ... .. ., �. -.. - . � , . � ' _ .. .. ,,