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HomeMy WebLinkAbout1173A 1174A '� WORKERS'COMPENSATION DECLARATION
'� . ins�reboraafcertifcateof WorkersrtCom'peosoton�insuran e" APPLICATION FOR BUILDING PERMIT �
! or a certified copy iher of(Sec.3800,lab.C.)
� PolicyNo61WBMX75 �mpa�y Hartford Group COUNTY OF lOS ANGELES BUIL�ING AND SAFETY
� Cerrified copy is hereby fum�shed. FOR APPLICANT TO FILL IN Bui�o�N� g65 5. Whitecl iff Drive
ADDRE$$
� Cerfified copy is filed with the coumy boilding inspeo BuaDMG -
f�o�depariment. ADDRE55 965 S'. Whitecliff Drive
' pore 7-24-87 Applicant BramalP� Calif_ aTv D.B. H�1 ziP �ocnurr D. . ���
! CERTIFICATE Of EXEMPTION FROM WORKERS' NO.OF BtDGS. NEAREST
COMPENSATION INSURANCE SIZE OF�OT NOW ON LOT CRO55 ST.
(This setlion need nof be completed if the permit is for one TRACT 42575 e�ocK LOT NO. 2 ASSESSOR
j h�ndred dollars($100)or less.) AMP BOOK PAGE PARCEL
i TEL. _
I cerrify that in rhe perfarmance af the work for which this owNER No. �S�NpP f� ��'y
permit is issued,I sholl not employ any person in pny monner 3151 Ai rwa Ave. #N SPECIAL �
ADDRESS Y � CON�ITIONS
so as�o become subject to the Workers'Compensation laws. O
c�rv Costa Mesa z�r 92626 �
Date Applimnl ARCMITECTOR TEL.
� ' TICE TO APPLICANT: If, after moking ihis Cerfificate of Aram Bassenian 752-1864 DISTRICT GROUP TVPE FIRE PROCESSFD BV C�
: � ENG�NEER NO. CON ZO E h
�; y�mption, you should become subject ro the Workers' �1 jJ �q �
�' �ompanwfion provisions a4}he Labor Coda,you musl fo�1h- AD�RE55 3990 Westerl y Pl ace 7t1�0 �v �1'� �,J � V� ' Q
! with comply w�fh such provisions or fhis permif shall br. TEL STATI571CAL CLASSIFICATION A�T. CON�O. tfT
'. deemed revoked. CONTRACTOR � g NO. ,��� �
t LICENSED CONTRACTORS DECLARATION ���, CtASS NO. � DWELI.UNITS
� I hereby affirm that I am licensed under provisions of Chapter 9 nODRESS No. 409610
� (commencing wi�h Section 7000)of Division 3 of the Business and ��� SEWER MAP
! Professions Code,and my license is in full force and effect. CITY CLASS B BK � VALIDATION
� SQ.FT. /(JO.OF NO.OF CHECK
� Licanse N�mber 409610 _�;�.�ias, B SIZE _ �TORIES 2 FAMIlIFS 1 DNE
p1 VALUATION
� Contractor ��B Dofe OESCRIPTIONOF WORK NEW L�J s y1.g--iiqq
� � SFR ADD � a+�rE�-.i;Auu ,
I om exempt under Sec. C�J
j ALTER ❑ ,//� - � �; �]G A
� 8.8P.C.for�his reasan PLAN 24 REPAIR s
i USE OF � , " o • °'��
} Date: EXISTING BLDG, DEMOL
i Siynature APP�I�ANT Bramalea Cal if. No, 850-10D1 FINAI�j � �` %5�4'
� OWNER-BUILDER DECLARATION PRiNT� DATE T�.�:Z,/�� g � f, : -t
f I hareby offirm thot I am exempt from ihe Contractor's License ADDRESS 3151 Ai rway Ave., 77N CO$td Mesa FINAL ,/` �`�V / ,V
� Low for the followin8 reason($e<tion 7031.5, Business and
p Professions Code)� PRC N � Sy �^�"�-u'�""` ���t'���
-y BUIIDING
� � I, as owner of the property, or my employees wiih AD�RE55
wagas as iheir sole compensation,will do ihe work and
� ihe sirucrure is not irtended or offered for sale(Secfion LOCAUiV
i 7044,Business and Professions Code). MOVING TEL.
� I,ps owner of Ihe properfy,am exclusively tonfrocfing CONTRACTOR NO. ��-'-� � �•��
p � with licensed contractors to construd the project(Sec- � qDDRE55 ',�° ° � " � �
j tion 7044,Business and Professions Code).
� REQUIRED TOTAL SETBACK F - 3
CONSTRUCTION IENDING AGENCY SET enCK VARD Hwv PROP.LINE Wi�TH I �ti�!�2,O O
I here6y affirm fhat there is a construdion lending agency for FRON7
Ihe performonce of ihe work for which fhis permit is issued P_L �a/i Ji�,�.���;
(Sec.3097,Civ.C.). 5i0E ��
' Toronto Dominion Bank P` �'�'�`;���
� Lender's Name_
�] • ,� ��,7 L�MA Ref.p
' 9 San Francisco. Cd�lf. PC.Fee$ PermitFee
� � Lender's Address '
3
� o I certify that I have read this applimtion and state that the 75• � Issuance Fee 10•50 LDNJ+P/C R
� � above information is wrrect.I ogree to comply with all County Invest�gmion Fee {� �/
I a e�dinances and State laws relating to building consfroUion, Toml Fee �uY"Z• LDMA Perm.M
� Q and hareby autho ize r esentotives of this County to enter
I M upon th a v antio ed erty for inspection purposes. ,. .
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