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HomeMy WebLinkAbout1169A 1170A WORKERS'COMPENSATION DECLARATION � , � here6y affirm �ha, � hove o certifica�e of conseni to 5e�f APPLICATION FOR BUILDING PERMIT i�! . insure,or o ce��ificate of Workers'Campensption Insuronce, o�a cernfied copy thereof(Sec 3800,Lab.C.) COUNTY OF LOS ANGELE$ BUILDING AND$AFETY PolicyNo61WBMX75 Q�mPa�y Hartford Group � Certified�oPy�s he�eby fu�nished. FOR APPLICANT TO FILL IN BUILDING g42 S. Whitecl iff Drive ADDRE55 OCenified copy is filed with the w�nty building inspec- BUILDING � tiondeportment. AODRE55 942 �. Whitecliff Drive Doie 7�24��7 Applicanf Bramalea Cd�lf. GITY ZIP LpCALITY CERTIFICATE OF EXEMPTION PROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SiZE OF�OT NOW ON LOT CROSS ST. (This section need not be completed if ihe permit is for one f ASSESSOR hu�dred do�lars($IOD)or less.) TRACT 42575' s�«K LO7 NO. 19 MAP BOOK PAGE PARCEL TEL. ry� I certify that in the performonce of the work for which Ihis OWNER ' O. _ ���� OP �� .-,�. permil is issued,I sholl noi employ ony person in ony manner 3151 Ai rwa Ave. #N I� SPECIAL � ADDRE55 Y a 'G��V�✓fJ CONDITIONS so as to become subject to the Workers'Compensation Laws. � Da�e qPP�i�a�� arr CoStd Mesd zir 92626 � "!)TICE TO APPLICANT: If, after moking fhis Certi{i[o1e of ARc��recTOR Aram Bassenian TE�- 752-1864 DISTRICT GROUP TVPE FlRE PROCESSEDBY � �9mption, you shoold become wbject to the Workers' ENGWEER NO. ; �ompensation provisions of the labor Code,you must forth- ADDRE55 3990 Westerly Pl ace #17� �� ��"-'� �' �� � � wilh comply wilh such provisions or this permit shall be �� deemed revoked. TE�� STAiI571CA1 C1A551F1 ATION APT. . ONDO. [q . CONTRAQOR O�B NO. � LICENSED CONTRACTORS DECLARATION "�� 409610 QASS NO. DWELL UNITS � , I here6y affirm thot I am licensed under provisions of Chopter 9 nDDRE55 NO. � (commencing with Seciion 7000)of Division 3 of the Business and ��� SEWER MAP , Professions Code,and my license is in full force and effect CITY Cta55 B gK � VALIDATION SQ.FT NO.OF NO.OF CHECK LicenseNumber 4�A6�n LicClass P. SIZE Ci.- STORIES 2 FAMILIES 1 ONE � VALUATION CoMiotlor ��B Oofe DESCRIPTION OF WORK NEW ; ❑�am exempt under Sea SFR ADD � , �� i ���' ALTER B.&P.C.for ihis reason A R'� / aeaniR f �r7� �(li(� +?g 6 ° '2 1 Da1e: USE OF DEMOL � EXISTING BLDG. � a J L�.£f.y � AP7LiCAN7 TEL Signature Pewr� Bramalea Cdlif. No.850-1001 fINAL� 3C .�J� " `�, �,,. OWNER-BUILDER DECLARATION DATE ' ��• = � ��% 1 hara6y affirm that I am exempt from the Contracror's License qDoee55 3151 Ai rwa Ave. #N Costa M2S FINAL / O � i F,�� � Law for ihe following reason(Secfion 7031.5, 8usiness and J�._._ �� Professions Code)� ' pR N By /�yL<'a- � I, as owner of the property, or my employaes with ADDRE55 � wages as their sole compensation,will do ihe work and , Ihe struclure is nol in�ended or otfered for sale(Section LOCALITV 7044,Business and Professions Code). ' MOVING TEL �.1 � 7�J�} � I,as owner of Ihe property,am exdusively conimcting CONTRACTOR NO. wiih licensed contractors to construct fhe project(Sec- qDDRESS j;'o o d o • j tion 7044,Business and 7rofessions Code). � CONSTRUCTION LENDING AGENCY SET�BACK� YARG HWY TOTAP OP.LINE WIDTH ) 0 5 C�'�D'� I hereby offirm that there is o construUion lending agency for FRON7 ihe performance of ihe work for which this permit is issued P.l. �+ �J�7,Q�1:i ($ec.3097,Civ.G�. SIDE lendei s Name Toronto Dominior Bank P L /� G�G�'W�'7 P.G Fee$ �6 Permil Fee �i761a' �DMA Ref.N , . Lander'sAddress San Francisco, Calif. / I cerfify Ihai I have read this application and stote fhat the •�� Issoance Fee 10•50 LDMA P/G# above information is mrrect I agree to comply with all County InvesYgaYon Fee ordinonces ond Slate lows relaling l0 6uilding mnstruction, To�al Fae �� � LDMA Perm.N and hereby auth ize re esentatives af ihis County lo enter , ��, $ upon ih a ve- nli n property for inspecti'n pur ses. � ,`� `_�� SEE REVERSE fOR E%PLANATORY LANGUAGE �' . . . Signp�ure of App imnt or Agent Date . ... . .. ..z.._..�,.... _.... .. _. . .. .. . . .... _..,_ ._...__ '_ _ . ._.__ . ._..... ......_.......7.....__ ___ . . .... _..... .._ .....� .. __ •Y__ q � . . � : ; � -:.. ,... _ 4 ,^ ' ' _ ...I. i .. �. _.q . . .. i " , ..�. • ' • • f� ' e .� . . • �,� , . _ . . . i.� .... � . � � �C t� : ! , � . � .' , ,... �:.: ; , . �-: ,'. 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