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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. ,. . +7 �l�---Q� SEE REVERSE FOR EX7lANA70RY LANGUAGE 3JJ � • „ � � 4-=i__' . . ` , o re o Npplicont or Agenl Do�e 4��y;b:.;� + , ' �' ; y � ( j � � � ..� ; � ' i ,�;,: - ; . : � �,3 { l � �'`a. , = , 1�, - i '' , r r � I Ra I . i • r ' , ;� ; - � ` _ -< ' � ���j,� � .. � ( '�j ' .._ � f ; � . � ; f :'�, i I� t� t � (� � � �� C ' t � , � +, .s. ' ; , r , ' i i � � ' ;� ; � ?� � � ' �� ' � � ! � - E � i 1 I q � � . r i il u j i ''ti-; � � , � ' � . _...� � � i � t , _ � �, rt. � t 3 W � , ' ' ... .. 5 � . � — • t� N . ' . 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