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HomeMy WebLinkAbout1171A 1172A WORKER$'COMPENSATION DECLARATION � � he�ebY a,f„m ihot t have a certificofe of mnsenl to self APPLICATION FOR BUILDING PERMIT � . insure,or a certificote of Workers'Compensalion Insurance, or a[erlified mpy thereof(Sec.3800,Lab.C.) � �1WBMX7 �� Hartfo.rd Group CaUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N . ompany � Ce�trfied copy is hereby 4urnished. FOf;-APPLICANT TO FILL IN Bu��o�N�' g66 S. Whitecl iff Drive AOORE55 � Cerlified copy is filed with the munty buiiding inspeo- BUaDwG g66 S. Whi tecl i ff Drive tion deportment. AODRE55 Date 7-24-87 Appliwnt Bramalea Cdlif. oTr D.B. Hi115 ziP �ocnurv D.B. Hi115 CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST � COMPENSATION INSURANCE SIZE OF lOT NOW ON LOT CR0.SS ST. (This settion need not be compleled if fhe permit is for one TRACT 42575 'L3 ASSESSOR hundred dolla�s($100)or less.� BLOCK LOT NO. /�.4P gpOK PAGE PARCEL TEL. U NE MAP I� '� OWNER I certify that in the performonce of�he work for which this a �� — �1 NO. permit is issued,I shall not employ any person in any monner 3151 Ai rwa �V2.� #N SPECin� � so as fo become subject to the Workers'Compensalion laws. P.DDRESS y (jd� CONDITIONS a aTv Costa Mesa z�P 92626 v �a1e Applimnt 0..'' 'OTICE TO APPLICAN7: If, after making this Certifimte of /+RCHITECi OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O �zmption, you should become subject to the Workers' ENGiNEER 1" d nian No. 52-1864 �a CONS Z� � .,ompensofion provisions of ihe Lobor Code,you must forih- ADDRE55 3990 Westerly Pl ace '�1�� ��S �y �i f� (� Lx,1 wilh comply with such provisions or this permit shall be n. deemed revoked. TE�� STATIS7ICAL C1A551iICATION APT. C DO. U) � CONTRACTOR O�B NO. .�1 Z LICENSED CONTRACTORS DECLARATION ��� QASS NO. � �WELL UNITS._L L i hereby affirm Ihat I am licensed under pravisions of Chopler 9 ADDRE55 N�� SEWER MAP (wmmencing with Section 7000)of Division 3 of ihe Business and UC. B Professions Code,ond my�icense is in full force and effect. � CiTV CL4SS gK � VALIDATION 409620 B 51r3ZEFTG— STORI�ES 2 AMI�ES 1 CONEK License Number Lic.Clasa � � VALUATION NEW Coniractor ��B Dole DESCRIPTIONOFWORK = � , FR ADD = I ] I, I A ,� �I om azempi under Sec ALTER i B.SP.C.for this reason PLAN 23 R REPAIR ❑ f d J"7 �'(�� {:;o `� � �[I Date: � USE OF � � : EXISTING BIOG. OEMOL ❑ f ^ 'S u F G'% � Si nat�re APPLIC/+NT TEL. 9 PRINT Bramalea Cal if. No. 850-1001 FINAL > / m „z q�;�;7�; ( OWNER-BUIL�ER bECLARATION DATE j 3E}/y�,J' � 1 hereby affirm�hot I om exempt from the Contractor's License i low for fhe following reoson(Saction 7031.5, 8usiness and AODRESS 3151 Ai rwa Ave., #N COStd Mesa FINAL� �'����"t��� � Professions Code�: , By irs.v � I, as owner of Ihe property, or my employees wifh ADDR SS wages as�heir sole compensation,wil I do the work and the srructure is nor intended or offered for sale(Settion �oCP,llTv 7044,Business and Professions Code). MOVING ie�. = 1 1 !�L�a � I,ps owner of the properfy,om exdo5ively confracfing �aNTRACTOR NO. o wifh licensed contrae�ors io construcl the projec�(Seo- }� m o . e � ; � tion 7044,Business and Professions Code}. AD�BE55 � REOUIRED YARD HWY TOTAL SETBACK F . � s � °��� � CONSTRUCTION LENDING AGENCY SET BACK PROP.uNE WIDTH I hereby affirm tha�there is a cons�ruction lending ogency for FRON7 u .: � r T 5 G �c� �he performance of ihe work for which lhis permi�is issued P.L. � m (Sec.3097,Ciu.C.). - SIDE �::'i•' �,r% v.l. �i.,G�'�..,t; i lender'sNome Toronto Dominion Bank LDMA Ref.p ; ° San Francisco Ca�lf. P.CFeeE r Pe�m��Fee �� 2��� Lender's Address � ' �' � � �carli4y thpt I have reod ihis application ond state thai the 75•oo Issuance Fee lo•50 LDMA PiC N �,� q a a � � o6ove informa�ion is correct.I agree to mmply wilh all Counry InvesYgoiion Fee or dinances an d State lows re la ting to bui l ding conslruc�ion, ioml Fee ��7' l�Nv1 Perm.M � o��'�,C 5 � < and hereby o th�r e re esen ati es of this Caunly to enter upon t e b e- ntion r er y for i�spect an p poses. 2�t � I �o � SEE REVERSE FOR EXPLANATORY tANGUAGE �U VJ 9 J�y {����V i ,gno� oi Applicanl ur Agen� D e ��b�� t> 0 F'i-.�L:�� x._....t � . E . .._ ___ _._.. . . .. : ... . . ... . . .. "'... ..._ ........ .'._...... '_' ."_ .._ _... ...__ __'.._..._ __.... .. _...,._ ;.� �1t. .�` . . ; : : i, _ i.. _...y_._.._.... , •... . _ , , _ . . ., . .. . . : : , ..... _.. .�i. . _ M ��R�� �_ ; ; .._ i - _ � ; , ; �i i : � - i ,� ' � ' . g ��e>" ? } , �. _ ,C�A � � T ,`, ' i.�` ( . . ; < '. ..; i :r i . ; , i ."'. . .�.3-.._..,. a,. 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