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HomeMy WebLinkAbout1153A 1154A WORKERS'COMPENSATION DECLARAiION r I hereby affirm «o� I hove a�e,,;f��a,e at�o�se��,o self APPLICATION FOR �UILDING PERMIT insure,ar o certifimle of Workers'Compensation Insurance, or a certified copy thereof(Sec 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND$AfETY PolicyNo61WBMX75 O�mpany HdY'tford GY'oup BUIIDING � Cer�itied copy is hereby fu�nished. FOR APPLICANT TO FILL IN ADDRESS 954 S. Whitecl iff Drive aCertified copy is filed with the co�nty 6uilding inspec- qD RE55 954 S. Whitecl'iff Drive tion department. oo�e 7-24-87 Applimnt BY'amaled Gdlif. cirv D.B. H11 ziP LOCALITY D.B. 'lls CERTIFICATE OP EXEMPTION PROM WORKERS' NO.OF BlDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOw ON LOi CRO55 ST. (This section need not be completed if ihe permit is for one -/ ASSESSOR hundred dollars($100)or less.] TRACT 425/5 BLOCK LOT NO 21 Mpp gOOK PAGE PARCEI TEL ���� MAP ] �/� �y I certify�hat i ihe performance of the work fo.whkh this OWNEN � NO. - NO. //7"ca'�� permit is issued,1 sholl not employ any person in ony manner qDDRE55 3151 Airway Ave. #N � SPKIAL C so as to bemme subject to rhe Workers'Compensation Laws. ' �DOG7 CONDITIONS Q arY Costa Mesa z�P 92626 U � Date L1pp�kaM � qRCH1TECTOR Aram Bassenian TE��752-1864 DISTRICT GROUP TYPE FIRE PROCESSEDBV O �'rJTICE TO APPLICANT: If, after making this Certificafe af ENGINEER N0� CONST. Z�F F` ;�mption, you should 6ecome subject �o the Workers' �i �! S W �ompensofion provisions of fha Lobor Code,you must forth- qDDrzE55 3990 Westerly Place 7t1�� �� /\_� � 1 � with comply wifh such provisions or Ihis permit shaii 6e 7E�, STATISTICAL CLASSIFICATION f APT. CON�O. � deemed revoked. CONTRACTOR � B NO. .y� LICENSE�CONTRACTORS DECLARATION - ���� 4d961O CLASS NO,�DWELI.UNITS�C-- I hereby affirm lhat I om licensed under provisions of Chapter 9 ADDRE55 N0. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and uc. B Profeuions Code,and my license is in full force and effect. � CITY CLASS BK � YALIDATION ' S0.Fj, NO.OF NO.OF CHECK — License Number 409610 Lic.Class B SiZE(�- STORIES 2 FAMILIES 1 ONE VALUATION O/B '• DESCRIPTION OF WORK NEW s Confractor -Date ADD � '� , ., �I � `',z a ��am exempr�nder Sec. SFR ALTER ❑ 9 �1 „ �, B.BP.C.forihisreason REPAIR ❑ s fs���C��/ f; k • m a Z 1 � Date: EXIST�iNG BLDG. DEMOL ❑ I �'�' i ��'J ' S�gnatula � APPLpgA 7T Bramal ea Cal i f. No.850-1001 pATE� �-�y�l y,Y a ���:i ���=� ' OWNER��BUILDER DECLARATION � 1 here6y affirm that I am exempt from the Cantmctar's License . qDDRESS 3151 Ai rwa Ave. #N Cost Me sa FINAL ����~�� � � Law for the following reason(Section 7031.5, Business and Professions Code): • p 8y �tt�- � BUILDING yJ I, as owner of the proparty, or my employees with nDDRE55 i �" wages as their sole mmpensation,will do the work and , iocnurv � 7 1 1 S Li�; the structure is not intended or offered far sale(Section I 7044,Business and Professions Cade. MOVING TE�� � j � I,as owner of the properly,am exclusively contratting CONTRACTOR NO. ii^ ° � • � � with�icensed<oniroctors to construct the projett(Sec- qpDRE55 � 3 � ¢ tion 7044,Business and Professions Code). �`�U� � REQUIREO TO7AL 5ETBACK � CONSTRUCTION IENDING AGENCV SET BACK YARD HWY pROP.LWE W��TN a " /(i J�C O I hereby affirm that there is a construction lending agency for FRONT fhe performance of the work for which Ihis permit is issued _ P.l. ��5��`��,�]. � (Sec.3097,Civ.C.). 5ioe Lender's Name Toronto Dominion Bank P` � o tTey-�� /�• . L�MA Ref.p Lender's Address San Francisco, Calif. P.CFee$ Permi�Fae r'tlT'7tl Cvf ' I certify that I have read this applicalion and state ihat the Q issuance Fee 10.5� LDMA P/C ri above information is correct.I agree to comply with all County Investiganon Fee • �1 ^7 ordinances and Stat laws relating�o building constr�ction, Total Fee 7�.�...uti /�'J IDMA Perm.p and hereby authoriz repre e lives of this Counly 10 enter upon 1 ab e- e lioned erty for inspecfi n pur oses. 2� � :l� SEE REVfRSE FOR E](PLAHATORY LANGUAGE at e of Applimnt or Ag � � � _._ __ _ - ._. _.._.._.. . � ,- : ;-----. - � - --.....__ .. _ ...........:__ ..._ !_._. ....- --- ---... _.... ,. ._.. . .-- ---- -.. _.._.. ----- -— , �. -:-,... - -, ; ,- .. . _ .. . ; <- . � ' . . .., -, _ _ . �.: :�� , - i • -: _ � �_ .� _,'=� i :� � � � ..., .,�, . _. , . . ., ( '.. _ , - 1 .. .- , ( ,.. .: ., , � . , ; r � _ _ � ±. r. � c f C t � � +;: :i ' i� : �: � .' �i. i � , _ i .. . ! .�... _ , .. 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