HomeMy WebLinkAbout1187A 1188A WORKERS'COMPENSATION DECLARATION
I � insureborafcertifca'teofWokesr�Compensationensuranef APPLICATION FQR BUILDING PERMIT L�
or a ceitified�opy iher,e�o/{f(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAPETY
Polity No.61WBMX75Ypqrnppny Hartford Group
� Certified copy is hereby furnished. FOR APPLICANT TO FILL W eu�to�NG
AODRESS 939 S. Whitecl iff Drive
� Certified copy is filed wiih the county building inspeo- BUi�DiNG
tiondeportmenf. ADDRE55 939 S. Whitecliff Drive
Date 7-24-87 Applimnt Rr�malp� Calif_ aTr D. . H'�� �iP �oca.uTv D.B. H71�5
CERTIFICATE OP EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOi NOW ON l07 CRQSS ST.
(This section need not 6e completed if rhe permii is for one TpACi 42575 � s�ocK LOT NO. 5 ASSESSOR
� h�ndred dollprs($100)or less.) MAP BOOK PAGE PARCEL
Bramalea Cal if., Inc:E� 850-1001 u�F zoNe nnnP �/ 7
I certify that in the performance of the work for which�his owNER NO. FP�� NO. ll7"J
�
� permit is issued,I sholl not employ any person in any manner ADDRE55 3151 A7 F'Wa�/ AVE.� �N � �� SPEqAL �
� so as to become su6jec�to�he Workers'Compensation lawa c�{� ConloiiiONS �
c�TY Costa Mesa z�P 92626 v
Date Applican� d."
'OTICE TO APPLICANT: If, a4fer making ihis Certificate of ARCHITECT OR , TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY C5
ENGINEER NO. y�p�
� emption, you should become subjea io the Workers' — C0�57.. y / F--
.,ompensotion provisions of ihe Lobor codg,Yo�m�5,fa��n- AooRess 3990 Westerly Pl ace #1�� �v �•:3 � � ►V W
. with comply with such provisions or Ihis permit shall he 0..
deemed revoked. TE�� STA715iICAL CLAS�SIFICATION �� AP7. UO. V3
CONTRACTOR NO.
�
LICENSED CONTRACTORS DECLARATION ��� CLASS NO. �}� DWELL.UNITS
�� I hereby affirm that I am licensed under provisions of Chopfer 9 ADDRE55 Na 409610
� (commencing with Section 7000)of pivision 3 of ihe Business and ��� SEWER MAP
' Professions Code,and my license is in full force and effect. CITV CtA55 B BK � YACIDATION
'� SGI.PT� NO.OF NO.OF CHECK
�� LicenseNum6er 409610 uc.Cioss B size G— sroRies �Z FAMIUES 1 oNe
��. � VAIUATION
��B Date DESCRIPTtON OF WORK NEW
Controdar AOD � s�� '
�I am exempt under Sec. SFR
� ALTER � .a ; I � ! Fl
B.BP.C.for ihis reoson PLAN 22 REPAIR � $ �v�I�U(�
Dafe: 115E OF DEMOL {t o u w ;�'�
EKISTING BLDG. ❑
Signature APP�PRINTt Bramalea Cd�lf. N0.85�-1��1 FINAL � �,,-� � m�� ��%:J
OWNER-BUILDER�ECLARATION DATE ��J��%r'�� .
I hereby affirm thp�I am ezampt from the CoMractar's License qD�RESS 3151 Ai rwa aV@. N Costa Mesa FINAL ° `"� � tS Fi J=i
Law for ihe following reason(Section 7031.5, Buslness and /,
P�ofessions Code): By ,.�J�_r,r.e<.� n S�r�4,.�7
� BUIL�ING �
I, as owner of the properly, or my employees with ADDRE55
wages as Iheir sole wmpensation,will do ihe work and ��ALITY ,
the strotlure is not intended or offered for sale(Section
704A,Business and Professions Code). MOVING TEI.
� I,os awner of the property,am ezclusively mntracting CONTRACTOR NO.
with licensed coniractors to construct the projec�(Sec- `�� � g'�'��`
fion 7044,Business and Professipns Code�. ADORESS ,
REQUIRED TOTAI SETBACK FR M *t' °g ° ` 1
CONSTRUCTION LENDING AGENCY $ET BACK �ARD NWY pROP.LINE WIDTH
I hereby affirm ihat fhere is a mnstruction lending ogency for FROM ( e+,rj�I.(>,(1�j
ihe performance of�he work for which this permil is issued P.L.
($ec 3097,Civ.C.). SIDE n m;:)'j(1(;i,��..
Lender's Name
Toronto Dominion Bank `` ^
�nnnn Ret.# C�2 f3—b%
_ lender'sAddress $dll F1'dtlClSCO, Calif. P.cFeea � '3��%6 ermuFee �' '
I cartify that I have read ihis applico�ion and stare tha��he �5.�� issuo�ce Fea 10•50 LDMA P/C tl
o6ove informo�ion is correcl.I ogree lo comply with all County In�asi�ganon Fee -�[ �
ordinances and State laws r latin lo building construc�ion, Totol Fee ��`i7'��^� LDMA Pe.m.M
and hereby au ha iz repie nr ti es of ihis Counry ro enter '
opon the abo - en ioned e y for inspecti n purposes.
r � SEE REVERSE FOR EXPtANATORY LANGUAGE ���� � �
Si nor�r of Applimn�or Agent Dat
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