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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 , �� \ ,..... .._:�_._....... ............w_....- ----__ _ .. _.._,.. . .. �-- --- .... _..---- --- -- _- --- -....------ ---... ...... ... ... _ - - , � ��, �_ y,l.�., . ., _ , , j ;;;, , - _ i �i -��" ., 3 . , � ��•i�. ,1 . � „ ' �r � '-' � ` � . ..._ij � 1 i <' i j ( � � � . ,: - � .. . _ .a . A. .. �..___ . � ` ;_ , C. 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