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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' . , . _... ,--- .... ;_., . . __. .....—---...._......,..._.. ......�_..._a,.._......,_. �- ,.. ..�.., ...� ... � .,c _... _ _.. .._ ---............... .. ._ __ ... ... ----.. _ ----,-----� -_,._.�3 :, - � ;� ; ; � , . � .. ... .,., ,� � .. � a ,.� ,.. I �.. . . ,a , p�� ' - _ . ` i:L � . �.. . . . ' 4� �r �n :� , F z..� . - .�.. " . . .. .�... `��1. � ._ ' . . � .. . - i . •_ . ' ' "' ' (' , � 'Y . . � - . " : �tl �) ;. `1... 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