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 . �
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