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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