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HomeMy WebLinkAbout1175A 1176A , WORKERS'COMPENSATION DECLARATION G, � insurebor�afcertifcote of Workersr�Cw�pensationensu�ancef APPLICATION F�JR BUILDING PERMIT u or a cernfied<opy ther�9�f(Sec.3900,'ab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY a�YNo 61WBMX7�i�Q,�,Po„Y Hartford Group Certlfled co is hereb fumished. FOR'APPLICANT TO FILL W sunowc, av v nooaess 929 S. Whitecliff Drive � Cerfified ropy is Filed with ihe county building inspeo BUILDING 929 g, Whitecl iff Drive tion deparlmant. AD�RESS Date 7-24-87 Applicant Bl"dilld�2d Calif. aTr D.B. Hi115 zia LOCALITY D.B. H7115 CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be campleted if ihe permit is for ane 42575 ��• "uEss°R hundred dollars($100)or Ie55.� TRACT � BIOCK LOT NO, 6 f MqP BOOK PAGE PARCEL TEL. I certify that in ihe performonce of the work for which this OWNER Bramalea Cal if. Ine.N0.85�-1001 ����E Np � ,�• permit is issued,I shall no�employ any person in any manner SPECIAL p}„' so as to hecome su6jeci to fhe Workers'Compensation Lawa ADDRE55 � �G�U� CONDITIONS Q �,T., Costa Mesa Z,P 92626 �' Dme Applicam a !OTICE TO APPLICANT: If, after makin this Cerfificate of ARCHITECT OR TE� DISTRICT GROUP NPE F!RE PROCESSED BY O 9 ENGINEER Aram Bassenian No.752-1864 J � ,�„E �-- iemption, you should become su6ject to the Workers' 3990 Westerl Place 1�� r�� c�� '� j �'4 a .:ompensation provisions of ihe Labor Code,you must forth- � qD�RE55 'Y �� wi�h [omply with such provision3 or this permit shall be TEL. STA'ISTICAL CLASSiFICATION � APT. CONDO. fn deemed revoked. CONTRACTOR Q�B NO. �� � � LICENSED CON7RACTORS OECIARATION LIC. CLASS NO. �WELL.UNITS I hereby offirm that I am licensed under provisions of Chapter 9 AD�RE55 No. 409610 (commencing with SeUion 7000)of Division 3 04 the Business and LIC ��R MAP Professions Code,and my license is in full force ond effect. � CI7V CLA55 B 0K � VALIDATION 54.FT NO.OF NO.OF CHECK License Number 40�9610 �;�.ciass B size G- sroeies Z FAMILIES 1 oNe � VALUATION � Dale � �ESCRIPTION OF WORK NEW ; .� Conhactor � B ❑�am exempt under Sec SFR A�� , :'I � �;�;A AL7ER � � -`2. [J 6.8P.C.for this reason REPAiR ❑ � r�" "' ° °c". I Date: USEOF DEMOL ❑ A W�� r EXISTING BIDG. I ' ��J. /J Siqna�ure � APPpRINNT Bramalea Cdlif. No.850-1001 FINAL � g �4. � u `7�,;,'/ r�z OWNER-BUIt�ER DECLARATION DATE yrlv�p J� I hereby affirm ihat I am exempt from the Contractor's License 3151 Ai rwa Ave. #N COStd MQ S Law for ihe following reason(Section 7037.5, 8usiness and ADDRE55 .Y � FINAI (����-�7 Frofessions�ode): ' PRE EN gY i�2L2G��� � BUILDING I, as owner of the property, or my employees with aooaeSS wages as the�r sole compensation,will do the work ond �OCAUTv �he svuc�ure is not intended or offered for wle(Section TEL. , _ � � i.6� 7044,6usiness and Professions Code). nnOVING � I,as owner of ihe properly,am exclusively contracting CONTRACTOR N�� a n o � with licensed contractors to construct the projeU(Sac- qDDRE55 � 9 1 tion 7044,Business and Professions Code). REQUIRED YAR� HWY TOTAL SET6A I %�?Q�,(j(� CONSTRUCTION IENDING AGENCY . SEi BACK PROP.uNE wiDTH . I hereby affirm that there is a consiruaion lending agency for pgpryi r, v(;�; _ the performance of ihe work for which ihis permit is issued - P.L. C C�,r_ (Sec.3097,Civ.C.). SIDE Toronto Dominion Bank P'� L`�� C/�� � Lander's Name - �O� -`j l�hM rtef.M � San Franci sco, Cal i f. P.C.Fee$ . Parmit Pae ' Lender's Address '� � I cartify that I have read Ihis applicalion and stote that the 75.00 �ssuance Fea lo•50 LDMA P/C q _ obave informolion is mrrecL I agree to comply with all Counry Investigarlon Fee � ordinancas and State law relating to building construction, Total Fee ��0�'�'4� LDMA Parm.k I $ �and hereby auth ri rep sent tiv s of this County fa anter � upon the bo e- �tion p o r for inspectio purp sea. r� �/� . I � � � � 1 SEE RFVERSE FOR EXPLANATORY UNGUAGF P . , i � Signa ur of Applicont or Agant �ote � � ' � _. '.........__............. .... _ .......�....._. _.... _ .. ..g..._. _ ,..... ...._ ................_.._ . ..'_ '.'_' __....'_'_ r' __ '_ _ ' _ '"'_ "....__ _ .._ _...'__..... _""_' " � �„ i.-.. .,.:, . _ ✓ ; ..- �. . , i _ ..�.. 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