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HomeMy WebLinkAbout1200A 1201A WORKERS'COMPENSATION DECLARATION � � I hereby affirm that I have a ceriificate of consent to self APPLICATI4N FOR BUILDING PERMIT insure,or o certifita�e of Workers'Compensation Insurance, or a certifled copy thereof(Sec.3800,Lab.C.J P��yNo.61WBMX7�YQ�,,,Pa„y Hartford GrouP COUN7Y OF LOS ANGELES BUILDING AND SAPEiY Cert�fied copy is hereby furnished. POR APPLICANT TO FILL IN eu��o�NG g48 S. Whitecl iff Drive ADDRESS OCertified copy is filed with the county building insper eUILDING � tion depariment. ADDRE55 948 S:� Whitecl iff Drive Dote 7-94-87 Applicont Rrama 1 aa Ca 1 i f_ arr ziP tocaurv D. '�� CERTIfICATE OF EXEMPTION FROM WORKERS' NO.OF e�oGS. NenREST COMPENSATION INSURANCE SiZE OF�07 NOW ON�Oi CROSS ST. (This section need nof be complefed if fhe parmif is for one TRACT 42575 '� BLOCK lOT NO. 2� MAP BOOK PAGE PARCEL hundred dollors($100)or less.) OWNER Bramalea Cdlif., I11CNo 850-1001 use oNe r�v+P I certify that in the performance of the work for which ihis NO. f � � permif is is5ued,1 sholl nol employ any parson in ony manner 3151 Ai rwa Ave. #N �� SPECIAL � p�� � so os Io bemme subjact to ihe Workers'Campensafion Laws. ADDRE55 .Y � p �, CONDITIONS p arY Costa Mesa z�P 92626 � �'. Dafe Appiicpnt ARCHITECT OR TEL. � ; ?TICE TO APPLICANT: If, oFler moking ihis Ceriificate of Aram Bassenian 752-1864 DISTRICT GROUP TVPE FIRE PROCESSEDBY � i emption, yoU ShOu�d 6ecome 5ubje[t �o the WorkBrS' ENGINEER N�� CONST. q � � �.ompenwtion provisions of ihe Lo6or Cade,yo�musf forlh- ADDRESS 3990 Westerly P1 ace #170 �� r�.,� N � with mmply with such provisions or ihis permit shall be TEL. STATISTICAL CLASSIFICA710N APT. ONDO. /A , deemed revoked. [ONTRACTOR ��B NO. _L� 'Z ��� LICENSED CONTRACTORS OECLARATION "�. 409610 CLASS NO.�DWELL.UNITS�� -� I I hereby offi�m�hot I pm licensed under provisions of Chopter 9 ADDRESS NO. SEWER MAP �. (commencing with Section 7000)of Division 3 of the Business and �i�. '� Professions Code,and my license is in f�ll force and effect. CITv CLA55 B BK � VALIDATION ', B 5�.fT. NO.OF NO.OF CHECK ���, License Number 409610 Lic Class StZE — S70RIE5 2 FAMILIES 1 ONE yA�UATION � CoMractor OIB Dote DESCRIPTION OF WORK NEW � S � � 5FR noo ❑ ' I am exem t under Sec. � P AUER � �/ :. ; i�l�A �'� 8.&V.C.for this reason PLAN 26 R � REPAIR s � �)`, � � . ' lJSE Of � L.��Ci+tl� :.! .s �:i a L� '. �ate: OEMOL � E%ISTING BL�G. � Signoture APPLICANT TEL FINAL ' g�'.���.�j OWNER-BU�LDER DECLARATION PRMT� Brama l ea Ca l i f. No_ �5 0-1 0 0 1 DATE ��/?C'�� i I hereby affirm that I am ezempt from ihe ContraUor's License J' � 9�l����C�`"�r � Law for the following reason(Section 7031.5, 8usiness and A�DRE55 1 1 Q 1/ N FINAL 9 Professions Code): � pR T By .�'z'`'�'a-� G �L'.2�`'"'�7 ! BUILDING I, as owner of ihe properly, or my employees with ADDRE55 � � wages as iheir sole compansation,will do the work and ' j �he structure is not intended or offered for sale(Setlion ���A��T� I 7044,Business and Professions Code). MOVING TEt. CONTRACTOR NO. � � I,as owner of the properly,om eaclusively contratling �7 2 ti,� � � wi�h licensed contractors to construct the projea(Sec- � qpDRE55 ! fion 7044,Business and Profes:ions Code). �y ,� � � m � REQUIRED TO7AL SETBACK � CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH � � I hereby affirm thdt fhere is a wnstruction lending agency for FRONi � a �b'J(]O � the performance of the work for which this permit is issued P.L. � (Sec.3097,Civ.C.). - SIDE e u'�(?„� ;1.: P.L. ` O.,� � Lendar'sName Toronto Dominion Bank �j�/ �p n. �����..,��� I m � P.C.Fee 8 ��T7 Pe m�it Fee �/J •1�a ���'Ref.N tender's Address Sdil FT^d11C1 SCO� Cal i f. ' i � I cartify ihat 1 hove read ihis application and sfate tha�the �5•�� iseuance fea 10•50 LpMA p/C M above information is correct.I agree to comply with all County . Investigailon Fee � $ ordinances and State I s ralating to buildfnq consrrucrion, Toral Fae � �� LDMA Parm.N and hereby a fh rize r res tives of this Ca�nty to anter � upan tha o - anlio e r eny for inspac'on pu oses. �a� � m , � SEE R!YlRSE FOR EXPLANATORY IANGUA6E �'�' Sign re ot Appli<ant or AgeM Data 1.. ... _.. . .. . _ . . ....... . .. .-_ _._._—..._ .___.__.._ ._.___ __ ...___. . .. _. � , . . ._. . ...._...... .. . _ .. __ . _ .._. .. . __... ._. . , _._.. ... . _. . , - - - — -._.... _ .,_ . , . _ — �,,. ..: . .. ; ; „ . : : . ��� � .'�. . ,� � " '� ' � w " i . , . f � - 1 3 4 `I ' 7; � . � ; ; I ,�} t,. ; ' - .. \, � �= • t' '�� • i � , '' ! _ � ... { .. _�, � i � i� : , _ ;,� - : .y €p : ` _, � 7 . �� ' ,) yf �" " �' 3 �., ,�g � C � � � t� "=7 tl i. 3 � ` ( ' ' _ _ ' , � t i : 5 ,�.-�.-��"l� ' 1 s -3 f Cti ; � W q , 3 i i � - � ' ^ � . 1 � � :' . {' �� f ;' � " i � ; ff � i i �t � •� ( ( � � ��� . '. . _ . ' ;! ' : i (�. ( � � ' ( ' k � � � . i' E . 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