HomeMy WebLinkAbout1191A 1192A WORKERS'COMPENSATION DECLARATION /'�
I hereby affirm 1ha1 I have a certificate of mnsent to self qpp��CATION FOR BUILDING PERMIT
insure,or o rertificate of Workers'Compensation Insurance, !�
or a cer�ified copy�hereof(Sec.3800,Lab.C.) �
Policy N�IWBMX75 O�ompony Hartford Group COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Ce�tified copy is hereby fu�nished. FOR APPLICANT TO FILL IN BUILDING
ADDRE55 9�0 5. Whitecliff Drive
� Cert�fied copy is fi�ed with rhe county building inspec- BUi��ING
tion departmeM. A�DRE55 ��
oa�a 7-24-87 Applicant Bramalea Calif. aTY D.B. Hills Z,P �ocAUTv D.B. Hills
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BL�GS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT GROSS ST.
(This settion need not be completed if�he permit is for one TRA�T 42575 g�OCK LOi NO. ZZ �+`SESSOR
hundred dollors($100)or less.) MAP BOOK PAGE PARCEL
OWNER Bramalea Cal if., Inc;,Eo. 850-1001 u5�,zoNE tiu+P �� _3
I certify thot in ihe performance of the work for which this K7y� NO.
permit is issued,I shall not employ ony person in any manner 3 51 Ai rway V2.� �f SaECIAL ��
sa as lo become subjeci to fhe Workers'Compensation�aws. ADDRESS cKO(?dC� CONDI710N5 0
c�Fv Costa Mesa Z,P 92626 v
Date Applicam �
�'OTICE TO APPLICANT: If, after makin this Certifitate of ARCHITECT OR TEL oISTRICT- GROUP TYFE FtRE PROCESSED&V Ca
9 ENGINEER Aram Bassenian No.752-1864 CO Z �
femption, you should hecome subject to the Workers' [� r{ST^ �
�ompensation provisions of ihe Labor Code,you must forih- qpDRE55 39 0 Westerl Pl ace #1�� �� �S•� � �r� w
with comply with such provisians or ihis permit shall 6e iE�. � p-
deemed revoked. D�B STATISTICAL CLASSIFICATION � APT. CONDO. t4
CONTRACTOR NO. �
IICENSED CONTRACTORS DECLARATION ���. ClASS NO. � DWEIL UNITS�
I hereby affirm thal I am licensed under provisions of Chapter 9 ADDRESS No. 409610
(commencing with Section 7000)of Divisio0 3 of the Business and ��� SEWER MAP
Professians Code,and my license is in 4�Ii force and effect. CRV CLA55 B BK � VALIDA710N
$q.FT. NO.OF NO.OF CHECK
licenseNumber anQ�O Lic.Class � SIZE — STORIES Z FAMILIES 1 ONE
� VAIUATION
Coniracfor ��B Dafe � DESCRIPTION OF WORK NEW �
SFR ADD ❑ s � .3 � c� ; f�
��om exempt under Sec. PLAN 2Z R A�TER ❑
B.&P.C.for 1hiS rep5on REPAIR � s IQ(� �� -� " ` �f � �
Date: .�� EXIST�ING BLDG. DEMOL ❑ � � ;, t� �.�3
� Sign0�ur8 APPUCANT TEL. fINAL '
PRINi� NO. - � J 1 ',2���
! OWNER-BUIIDf.R DECLARATION �ATE 3L� �l��� ` `�
'' I hereby affirm thot I om eaempt from ihe Controctor's License . qDORE55 3151 Ai rway Ave.� �N C.QStd Mesa /-
i law for the following reason(Sedion 7037.5,Business and FINAL y �'✓'.C f:"`i.3 7
� Professions Code)' � PRE EN BY �%i�lu�'-t-�'
� BU�LDING
! I, as owner of�he property, or my employees with � aooseSS
wages as�heir sole compensation,will do the work and ,
! the strucrure is not intended or offered foi sole j5ection �a�A�iT�
� 7044,Business and Professions Code). � MOVING TEL ,]'� j Q�N
� � I,as owner of the property,pm exclusively coniracting CONTRACTOR NO.
j with iicensed coMraclars to mnslruct the project(Ser qpDRE55 ���� p r � 1
� tion 7044,Business and Professions Code). �ri
CONSTkUCTION LENDING AGENCY SFT�BACK YARD HWY T�TAp OP.�LINEF M WIDTH �"���'1'�'�
I hereby affirm that ihere is a constroction lending oqency for FRONT � �a i�;� ���i.
�he performance of the work fot which Ihis pecmil is issued p.�. �
I (Sec.3097,Civ.C.). SIDE t,
� P.L. tI t;:7 E�"'FS l
i �endarSName TorontQDominion Bank
! W ���U LDMA Ref.#
� Lender's Address Shcl F1"dI1C15C0� Cd�l F. p,C.Fee$ '.�J��c�i ermir Fee '
� I certify that 1 have read fhis applicalion and state thot the �rj.QO IssuancaFee l�.�J� LDMA P/C N
a6ove in4ormotian is correct.I agree lo comply with all County Inves�igation Fee �`i
ordinances an Stata laws relating to building construction, Tmal Fee �`�f'� LDMA Pe�m.fl
and hereby o hori representatives of this County t enter
� upon t e b v -me io e perty fo�inspecli'n pu oses.
� SEE REVERSE FOR EXPLANATORY LANGUAGE � �� ,
� � ig �ure af Appiicon gant Dale'
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