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
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