HomeMy WebLinkAbout1149A 1150A � WORKER$'COMPENSATION DECIARATION
I� I heraby affi�m that I have a cer�ifica�e of consem w self APPLICATI��V� FOR BUILDING PERMIT LJ
. ` insure,o�a certificate of Workers'Compensation Ineuronce,
or o certified copy thereof(Sec.3800,Lab.C.) COUNTY OF l05 ANGELES BUILDING AND SAFETY
Poi;�Y No.61WBMX75 @�„Pa�Y Hartford Group
� Certi4ied copy�s hereby furnished. FOR APPLICANT TO FILL IN BUIiDING 971 $, Wh itecl i ff Drive
ADDRESS
Cerlified copy is filed with}he county building inspec- BUILDING
� ,�o�deportmenf. AD�RE55 g71 5. WhitecTiffi Drive
oare 7-ZG-S�AppiicaM Bramalea Ca11f. atv D.B. H1�1S ziP iocauTv D.B. Hl'��5
i CERTIFICATE OF EXEMPTION fROM WORKERS' NO.OF O�DGS. NEnReSi
f COMPENSATION INSURANCE S¢e OF LOi NOW ON LOT CeOSS ST.
� (This sec7ion need nof be completed if fhe permit is for one TRACT 42575 BLOCK LOT NO. 1 ASSESSOR
i hundred dolla�s($100)or less.) MAP BOOK PAGE PARCEL
� OWNER rama 2d �,d 1 .� ('1C.Np - USE ONE �+P 3� ' r.
� I certify that in the performance of the work for which this f1 �.'>� NO. / '.;3 ,
} permit is issued,I shall not employ ony person in ony monner ADDRE55 3151 Ai rway Ave.� 1tN e�{�� CONDITIONS �
� so as to 6ecome subject to the Workers'Compensarion Laws. Cl
° aTY Costa Mesa z�P 92626 �
� Date_ Applimnt ARCHITECIOR TEI. �
/>TICE TO APPLICANT: If, after making ihis Certificafe of ENGINEER AT"d Bd S hcl No. 52-1 6 DISTRICT GROUP NPE FIRE PROCESSED BY D
`emption, you shooid become subjeq ro the Workers' CON57. ZON � �
�ompensalion provisions of the Lobor Code,you must forlh- qDDRE55 3990 We5terly P1 ace #1�� %'J ��.3 '�j✓� � W
with comply with such provisions or Ihis parmit shall be
"s TEI, STA715TICAL C1A551FICATION A?7. NDO. fA �
¢ deemad revoked. WNTRAC70ft Q B No. � � �
� tiCENSED CONTRACTORS�ECLARATION ���� 409610 CLASS NO. DWELL UNITS "
I heraby affirm that 1 om licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
� (cammancing with Seclion 70W)af Division 3 of the Business and LK. �
Professions Code,and my license is in full force ond effect Giiv CLASS 8 BK � VAUDATION
4D9610 B SIZEfT_ SiORI�ES 2 °;�°�s 1 o EN
4 License Number lic•Class
� NEw ,VALUA710N
� Contracfor Q�B Dpte `' DESCRIPTION OF WORK qOD � ;
$' ❑�om eaempt under 5ec SFR , � � p S,;�,
� ALTER � /
�' 8.8P.C.for this reoson att � REPAiR ❑ � 1J��aG(�i �. % • - ;;�'i
� USE OF �
Daie: DEMOL � �� ��y
i,, � EXISTING BLDG.
�I Signature APPUCAM TEl FINAL . ,.
PR,N, Bramalea Calif. No850-1001 �' ,�y ,:�.,
r OWNER•BUIIDER DECLARATION pATE Li � � ==-�--
�Y, I he�eby affirm that I am exempt from the Contractar's Llcanse pg a
' law for the follawing reason(SecHon 7031.5, 8usiness and ADORE55 3151 Airwa Ave., #N eS� p�ryq� _ .,: G,��S� J.
� Professiom Code): 0Y �.Q,2sL�"
.. --� BUILDING
„ y� I, os owner of Ihe property, or my employees wifh AODRESS ,. �� ' ;;� �+�
7 wagas as th¢ir sole compensmion,will do the work and ,
e the structure is not imended or offered for sale(Saction �OCnuTY „ s ,�
� 7044,Business ond Professions Cade). hnOVthtG iEl. +� " `� ' '" .
CONTRACTOR NO.
� I,as owner of ihe property,am ezclusively contracting � �'�;,��r,L n
a wifh licensed controciors to mnstr�ct the prolecf(Sec- �- qD�RESS
Iion 7044,Pusiness and Professions Code). g �� . : -� �s
� REQUIRED TOTAL SETBACK � � �``"�'����
CONSTRUCTION LENDING AGENCY SET BACK YARD Nwv VROP.UNE wiorri
I here6y offirm thot Ihere is a canstructian lending agency for FRONT ��:C:t;"'�'i�
{ rhe performance of the work for which this permit is issued - P.L.
(Sec 3097,Civ.C.). SIDE ..
Toronto Dominion Bank P`
Lender's Name _
P.0 Fee 5 - Permit fee lDNu1 Re4.#
Lender'sAddress San Francisco, Calif. • ����� �
I certlfy Ihat I have reod this application and stote that the 5•00 Issuance Fea �'�•50 LDMA P/C N
_ above information is correct.1 ogree lo comply with all County Investigat��an Fee �,g�-�
ordinances and State laws relati g to i ding ronstruction, To�al Fee "�'���'Ki r-"�� mnM Perm.R �
ond hereby aufho i r present ive is County to enter . . .
� �pon the a ove- e ti ned p rty i spection purposes. }-✓ .
,�, ,�( :��
� SEE REVERSE FOR EXPIANATORY tANGUAGE j'�
S�nafure of Appli<ant or Agen� �ote , ��
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