HomeMy WebLinkAbout1151A 1152A i , WORKERS'COMPENSATION DECLARATION f'� � I hereby affirm ,haf� ho�e a csrt�fica�e ot consent to self APPLIC�4TION F�R BUILDING PERMIT � . insure,or a certifimte of Workers'Compensation Insuronce, or o cerlified copy Ihereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Poi;�YNo61WBMX75 Q�mPe�Y Hartford Group ❑ Certitied mpy is hereby fur�rshed. F0�2 APPLICANT TO FILL IN ADIDRES$ 959 S. Whitecl iff �rive � Certified copy is filed with ihe counfy building inspeo- BURDiNG tion depariment, ADDRESS g �o�e 7-24-87 Applicont Bramalea Cd�lf. aTv D.B. H711 ziP iocnurv CERTIFICATE OF EXEMPTION FROM WORKERS' No.OF e�DGS. NEAREST COMPENSHTION INSURANCE SIZE OF LOT NOW ON LOT CRO55 ST. �This se[tion need not be complefed if fhe permil is for one TRACT 42575 � e�ocK LOT NO- 3 ��' AUE550R hu�dred doliprs($100)or less.) MAP BOOK PAGE PARCEL TEL. US O +�P ��r I certify tho�in the performonce of the work for whith ihis OWMER ` � NO. — ��Nj ND. !����a'-Y permii is issued,I shall not employ ony person in pny manner ADDftE55 3151 Ai rway Ave., 7fN �D� SPEGAL � so as lo become subjeci to the Workers'Compensation Laws. CONDITIONS � c�,v Costa Mesa z�P 92626 � Dafe Appiicpnf ARCHITECTOR TEL. � �'.�OTICE TD APPLICAN7: If, ofter making�this Certificate of ENGINEER � NO. _ DISiRICT GROUP oP� ZRE PROCESSEDBY g ,emption, yau should become subject to the Workers' � � / ..4�' � p ..ompensation provisions of the La6or Code,you must forih- qDDRE55 3990 Westerly Pl ace �1�� 1b �'-� �V j I..Ll � with comply w�th such pravisions or this pe�mit shall be TE� II. deemed revoked. STATISTICAL CLA551 ICA710N APT. CO DO. V) CONTRAQOR O B NO. -�—� � LICENSED CONTRACTORS DECLARATION "�� 409610 ClASS NO. � DWELL UNIiS�_ � � I hereby offirm that I am licensed under provisions of Chapter 9 ADDRE55 NO. (commencing with 5ection 7000)af Division 3 of fhe Business and ��� SEWER MAP Professions Code,and my license is in 4ull force and effacl. CiTY CLA55 B VALIDATIOtd Sq.F NO.Oi NO.OF CHECK BK. PG. LicenseNumber 40�9610 �{c.Class B SIZE — STORIES 2 FAMIlIES 1 ONE ` VALUATION R O/S DOfe DESCRIPTION OF WORK NEW �X y Comractor s�"�q�Q SFR AD° � � ❑I am exempt under Sec. ❑ ALTER ) ] B.BP.C.for thi5 reaion REPAIR ❑ s /s���OC� " � � "�� � a � � Date: USE OF EXISTING BLOG. DEMOL ❑ �� ,u e v � Signature APPLICANT TEL e( 1 PRINT) Bramalea Calif. No.85Q-1001 fINAL �/ � ; o� 4,.,.� � OWNER-BUILDER DECIARATION DATE .1�� � � � c_.. I hereby affirm that I am exempt from the Contractar's License Law for ihe following reason(SeUion 7031.5, Business ond ADDRE55 3151 Ai rwa A FINAL ,3 m 0�.' �S�'�� Professions Code): PR EN BY r�lltir'�"�'"' I, as owner of Ihe p y, y P Y BWLDING i'a c�i"O� � � pro ert or m em lo ees with A�DRESS � J wages as their sole compensation,will do�he work and LOCauiv ' �l the structure is not imended or offered for sale(Section 7044,Business ond Professions Code). MOVING TEt. �� � r��� j. O I,as owner of the properry,om exclusively controcting CONTRACTOR NO. p ' wiih licensed coMractors ta construd the project(Ser {j w e e �a � ' tion 7044,Business and Professions Code). ADDRE55 � CONSTRUCTION LENDING AGENCY - SET�BAC� �AR� HWY TDT'4p�5E�TpA�NE WIDTH I � �r-�5'�c I hereby affirm ihat ihere is a construciion lending agenty for fRONT "' I C�.O�'-�� j the performanca of the work for which this permit is issued P,l. i (Sec.3097,Civ.C.I� SIDE �. � Toronto Dominion Bank P` ��'�8�87 ` lender's Name �}�—�q/' LDMA Ref.q ° San Francisco. C(���f. P.C.FeeS erm�tFee ��"��+'�vlL' �S , � Lender's Address 3 I cerfify rhat I have read this appiication and state that the �5•�0 Issuance Fee 1�•5� LDMA P/C p above info�mation is correct.I agree b comply with all County Investigotion Fee �7 ordinonces and State laws relating to building construaion, io�al Fee � /�' LDMA 7e�m.p and hereby authori repr entat'es of this County to enter e upon the b e- e tione ro for inspecfio purpqses. �j �1 SEE REVERSEFOREXPLANATORYLANGUAGE � � � - �� igna of Applicanl o.Agent Dole � � _.. ...... ... . _. .. _ .... .... . , _ - ; . -- - - - -- - - _. _ . 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