Loading...
HomeMy WebLinkAbout1155A 1156A WORKERS'COMPENSATION DECLARATION I hereby offirm ,ha, I have a cer�ificate of mnsent to 5a�, � qpp`�CATION FOR BUILDING PERMIT � insure,or a certificate of Workers'Compensation Insurance, or a certified copy fhereof($ec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY voi��rN�i1.l�Bl�(Z5�Eompany Hartford Group � Cerr�fied copy�s hereby Furnished. FOR APPLICANT,TD FILL IN BUILDING g30 S. Whitecl iff Drive ADDRES$ � Certified copy is filed with�he county building inspec- Bui�DiNG tiondepartmeni. ADDRE55 930 S. Whitecliff �rive oore 7-9a-R7 Applicant Rramalaa Cal if, citv ziv �p�A�iTY p CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BL�GS. NEAREST COMPENSATION INSURANCE 51ZE OF LOi NOw ON LOi CRO55 ST. (This section need not be complefed if the permit is for one s' ASSESSOR hu�dred dollars($100)or less.) TRACT 42575 ' s�ocK LOT NO. 1�i MAP BOOK FAGE PARCEI OWNEk Brdmdled Cdllf. I11C.No.850-1001 us oNe +�wr I certify Ihal in Ihe performanw of ihe work for which this 1� s� NO. � ^3"� permi�is issued,I sholl not employ ony person in ony monner 3151 Ai rway Ave., 7fN r� SPECIAL � so as to become subjeci to the Workers'Compen5afion Laws. A�ORESS !+d fa CONOITIONS a c„Y Costa Mesa Z,P 92626 �? Dofe Applicanl [X 7TICE TO APPLICANT: If, after making this Cerfificole of ARCHI7ECT OR TEL. DISTRICT GROUP TYPE FIRE PRDCESSED BY O ENGINEER Aram Bassenian No. 752-1864 �:mption, you sho�id hecome subjea ro ihe Workers' CON Z I-- �ompensation provisions of the Labor Code,you mus�forth- o �[� ��'j �j/� � � W wilh com I with such �ovisio�s or fhis ADDRESS py p permit shall be TEL STATISiICAI C1A551FICATION APT. . CONDO. t�A deemed revoked. [ONTRACTOR ��B NO. .�.�/ � LICENSED CONTRACTORS DECLARATION ���. aASS NO. � DWeLL.UNIiS_� I hereby aff�rm ihot I om licensed�nder provisions of Chopter 9 AooRE55 rvo. 9610 (commencing with Section 7000)of Division 3 of the 8usiness and ��� B SEWER MAP Professions Code,and my license is in full torce and effect. Ciiv C�.455 gK � VALIDATION Sq.F NO.OF NO.OF CHECK License Number 4U9610 Lit,Class Q SIZE ' S70RIE5 2 FAMILIES 1 ONE VALUATION � �ESCRIP710N OF WORK NEW Contractor_ ��B Dafe ADD s � / �I om exempt undar Sec. q�iER ❑ e.&P.C.for this reason PLAN 25 R REPA�R ; �,�-3��f�(� �� i �+:F Date: USE OF DEMOL — EXISTING BLDG. Signatura APP��CANT Bramalea Cal if. TE`�850-1001 FINAL �/ � � :%� � A �2 7 OWNER-BUILDER OECLARATION PRINT N0. DATE `f�� �,?" I hereby affirm tha�I om axempt from ihe Contractar's License . qoDkE.SS 3151 Ai rway Ave., #N �OStd Mesa r � � �4 7 7�� Law for ihe following reason(Section 7031.5, 8usiness and FINAL (/ Protassions Code): By ,�-Cc.c..t.tr� „ q� 'I <�j�z; � BUILDING ""' ` I, as owner af the properiy, or my employees wifh AODRESS wages as their sole mmpensation,will do ihe work and ' d�,t:�`""�i 7 Ihe str�cl�re is nat intended ar offered for sole(Section �OCALITY � 7044,Business pnd Professions Code). MOVING TEL. � � I,as owner of Ihe property,am exclusively conhacting CONTRACTOR NO. with licensed contractors to construct the proiact(Seo- qDORE55 �'1 1 5 6 A , tion 7044,Business and Professions Code). REOUIRED TOTAI SETBACK F � b ' � ,� CONSTRUCTION LENDING AGENCY SET eAGK VARD HWY pROP.LINE WIDTH n 0 I here6y affirm that fhere is a consfruction lending ogenq for FRONT Ihe performance of ihe work for which Ihis permit is issued p.l, � : � o'7�r��� (Sec.3097,Civ.C.�. SIDE r� � lender's Nome Toronto Dominion Bank P� � °� �����W� '�' LDMA Ref.N Q�C�""�5 / " tender's Address San Franci sco� Ca�1 f. P.G Fee E � rmit Fee , � � g 1 ceriif thot I have read ihis a lication and state lhat the � Y PP 75•0o Issuonce Fee 10•50 LDMA P/C N _ above informalion is correct.I agree ro mmply with oll County Invesiigation Fee .�j�T7/��'' ordinanms and tate la s raloti g to building construclion, To�ol Fee ^�""'/`^-�` LDMA Perm.# and here �� rize r r s t ives of this Coonry to enrer ! � upon e bo e e io rty for inspedi " porp ses. � e SEE REVERSE FOR EXPLANATORY IANGVAGE �� � �alure of Applimnt or Agenf Dota . � i ... , ._.. ...._.......-- — _ _.. ... . -- - — - — --- �— ---— ----. _ ._ _ .. _ _ .. _ _ . .... � : � \ , _ , E 3 , , � _ , _ , � , ! :. � '. i -.- .., ,_ ,... . ;. �� v `�`' � ,�f� ; . .- � - i � ;I; ( • ''�, � 'iti � 'r - ; i! �;' ' i � '�,�� 4� . � E l r�; } � , . - 7p i t � ( � �' � � i, � , � '_"+ ' �' "- I' s y' � `�'`� � � � : ^' a , t �` � ' i i �. , � f o l. i e� i.� , ' { ,., ; .. , _ ,.1 t ,., i , •; i : : � �� �, �1( t' j i1 ' ' " C i � j }' � r`'� _. � � _ � � . � � k ! i� I f � _ I , „ _ d�- � ; .� ^FC' . 1 4 I ' �, ' � �� � � � �,`^�.�� i, i 5 � t�.�/ � i ;e �� i'_ � � i ., � � j � � ; � � i ��~ � � I �.s• � � I � �, � t � � ' ' ' „'�,'a . �- . .» , ? i � f � � '� 1 � , , ( , I ; ` i � } Y J ii :...._..4.____. �..__._ .. . : ...... _. . _.._ � il I � i !, ( ; •) I 1 i ' f�` I , � j> E : ; , <" ; I ' i j � ,, -. : , 4 � �€ � _1+ .-._ �� � ' � �..,..... ,) •_ � � � � _ I � f j ( t i� � ' 1� I � , , � ; =,.��;` , '� ��� • , ; � i , I, E _._._ ; _ `, � c ' ti'" + .._ _.. _.._.. . ._ _ ._ _ _ _ _ � _ 4 ,` �' � �'•' � �' i,..__,.v ._.6 � : � i"..... i i._... - e � ! _,`�`i{� j s'�-_ ���k.,�.,"��:y.t..s.�"�� � � �. �. ..1. ..�� _..�.. --5 i i i i i'` E H ; ' 7 ij_`?:� ! A �. � I `^ `� .\ �.4 �1 � � ' � ( ; � s�`. � �: i _� .. . ,.'._ . + � . _ . - -r- . ��. , ._w_�... --- ¢ - -- , - ,�-..__ ` � il � � , , i � ,,��,�t-�� i _ � � . .. . _ �.. .._-- -—. jv�__ ._..._; _.. -- — — � � 3 _ , ,, � �. ,� , „ �,�� �s . "— — i . . i� .: :, � � � ;�� ; ' _; } � ( . , ' � ' F� � .. � � I . . : _ � �. :.. ,., . � ' `." i. . ... F. :r< !'r. � r '. � ,� j ;! .z § , � ' c? . � . 1 :a 1 � I I � k� � �`� ( !�� r.. '.. ��i ' ' i � � �R �� ' _.... ._ ' ' ._. ..."'"' ' ... . _...._..._�_... "" "._ �) . ...1_.. . 'it� � •.� � . ,� ; I .., j 1�� i+ 1 . .� .. � , t . ! Q . . - � .r, . . j . , i ' . • { i\ . .� : � . ,� � � :i { ��- � .� � , s � -. w � �� ; � ;; � I . .-a : i •, � � : ; , � F: .., . � _..1.. � i. � - ,, � ' ? I ( ; I ; ! n �. ' �.. .I, . . : : , ,: , ; ; � i ; ,> ' i ; I : i , . ; . . � . te' � : 3 : '� _' '._ ""_ "" "..�_ ._ "'� �) � 3 1 , �t k 4 � . : � � ; � i"7 i ,^ � ` I i � � j i , ; ' ;':. ��' � I } , i 1 ; i � 1 � ,a;o � . � . � � � ( � � ; ; I i � � ;, � � � " � I � � I� � � � i �� � � I ! i { j , �; � � ( � i y � ( I � � � i ,� � ` f� � � � ' � � ;) � � � � � � i � I� o."� � � �' �; m,�� j � i � f � , � � � l -;-. �_.._.__ �_--� � . . .¢ --- {L.. � ,�— -- - - - - - r-- � I)_ � -- �,�__-�----3 ; 1 . . ,, , I __ _ , � � . �... �.. + l � , ' � E , -- -�-� T -7 _�--__� -� � � a i t i �, { � �' ;� ��' � � i� 3 � t i � ' $ ( j ; i ; i i ; . .� � 1 f � � � � � �.- j � C f � i i 4 1 j i i � ! 1 � � i , { , . � I � ; I 4 ; � i � I I ` � � � , � i � � � ;i �' �' ` � � � i f � � � � I i � �. � � � � � � ' i ,S � � , � ' ; : '; j ` � � i i � � i � � i I � i ? � ( ' 4 ( { � �! ( � � � � � : ' i ; , -} � E � � 1 � � ! I , 1 � I : i ; ` ' " ` ; f � � � : = i I ! i ; � ' � � I � i i � � f � � i # ( � i � � � � � ) t � � ( � � ' . � � ; 1 , � 3 •� � I . ( s � 1 � � ! I � � � '';� , � ! ' -� ! � i �'n� � � � 1 I � � � i � � ..� .k j I � � � ' . � ( ! i � � I .. 1 I . i," � � 1 i , i � � � j i � ; i i � � f � 1 � .i j � j �;� � ' � � ; ? ! j � i � ` i � ( i � � ' � !� I � i j i I ��� � i . I i � � I : � � :_�I I � � I � �.. , � � i ; � , 4,� � � � � � � � 7 � � �..R� !!! � � i i � ' . ; � � '�} y �' � � ( ' � i � . .f � � 1 � ( � E � ' � ' � � ' � 7 . ,� 1 � � � � F .�. i i S i � ' � � j � � � ( I � j [ � f. i : � f i ; : : � � ( � � � . � � t1 j� { � ' � � i ! j ' . I i ( � S � � � ( i ' j i i ' � i t ( � i � � 4 i � 3 ( ! � i � 1 � � � � � � + I � � i Ek � ( � 4 , I i � � f � � i � ' � � � 1 j � j � j 1 � � € � � € � i i � � � I � � � � , , � ; � � i � , ; i i � � ! 1 i l � � i � , ' i I . ; � f � � i j j 1 � ; ' J - `a' ., .. �. P= � ^ ......w„:=' r. r "`. ..'�`.. ', v ' i I � , � w � G „ . ; `� � c. " ' . � , � � , � � � �. � N ',� ' ., � �. y " m , r„ � F.a. - 4 x, " '" %n : � i ( � I 3 ` a y i �'9 '^^�., re �' _ .. �L �. :r t t � ' � � � � � �.. � "�` 4 ,,,,�4 ,a � �' � i j � f 1 �J ;-. __� "�,. =` _. , _ ^ ^ . ._ ,. � I � ' � ; ^ �' n '7 ... .....,n r �.i �j 5 v ' .'3.' ,:5 ' � j ' ` ''. � u .. � � � �„ `) ` Y . .H,-'. � I � � � � � t x ^'^ T� i':._,,. ti _ ^: .,� � ,:.. _+5 e'. I � ! �g � � � ? ., � y �i . "� , f &;., .R' I i � 3 � • . I � � i , :3 � � � _":,}: :: �'. ... ' `;�w -«� . _ , � i � I� , j i � 9 w � �7 � _ �"_ 4..� "� � ` - .� ... � ' p1 „ ry y '" ,: � � � 9�� � L �y �' � s � _, i i � f ; , � _�.; I ' �. =; �:. � — �:. ,� � � � _ -� � i � i .j I � i i � .e� � 3 ;n `-" � .. " � �' . �� �? -- . „ j � I � ' 3 . 3� i � � , � ,a, �,. _ . . ��?- :. -.. 2' i , i dSf� � " S' `J `� ' (i ' .. . i i � I ' � ' � ��� � � � �` .. . � - ' x .� "' �� • . i � � r i i � j ;.. � _ . - z " . � • .a � s rv � , _ � � � - ,f, � � ? j � ( � 1 �- .. �' :� � " f ( j ! ( � � � " � i y � ; : __ ' . � c.;.:y ., rm �( ' � g q � �`. r ,� c ; € � j i ( I � � � x 4 � ' M , -, - .� .. ,. ' w,, € � } ' . , i t . -c, _;y �- , . 'r'. ! 1 � .. ' ( , � � ' 3 � € F .. � r ' 'K .. .. � . .. . _ { ! � j � � � C � tr " • � ' ? ' i � � ! � � � `� � m i ' �`_ _ .. , .. q� a`-- .. , � _. ., , • .-- � . . , _ . . ,. 4 � , . .