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1202A 1203A
WORKERS'COMPENSATION DECIARATION � I inwrebor�afcerr�ifcarteofWokesrrCompensatlonlnsurancef APPLICATION FOR �UILDII�lG PERMIT o�a cerrfied copy thereof(Sec 3800,Lab.C.) C�UNTY OF LOS ANGElES BUILDING AND SAFETY Poi;�YNp.61WBMX75�@�„pa�Y Hartford Group � Certrfied copy is nereby F�rnished. FOR APPLICANT TO F1LL IN ew�ow� AooREu g . Whitecl iff Drive � � Certified copy is filed with the county building inspec- gUILDING fiondeportmenl. ADDRESS 972 �S. Whitecliff Orive � Dote 7-24-87 Applimnt 6ramalea Calif. c�rv z�P �ocnurr D.B. Hills CERTIfICATE OF EREMPTION FROM WORKERS' NO.ov a�oGS. NEAREST COMPENSATION INSURANCE 5RE OF�O7 NOW Otv�07 CRO55 Si. { (ihis section need nof be complefed if fhe permi�is for one TRACT 42575 B�OCK lOT NO, 24 , ASSESSOR hundred dollars($100)or less.) MAP BOOK PAGE PARCEL TEL. � I cerlity that in the performante of the work for which ihis OWNER � NO - ���Nn OP �I �� ; permit is issoed,I shall not employ any person in any manner ADDRESS 3151 A i rway Ave., ffN � `� SPECIAL ��� i so os to become sabjee�to ihe Workers'Compensation Laws. �G�r_id-1� CONDiilONS �y ; ��TY Costa Mesa z�P 92626 � �ate Applicant � j ARCHITECT OR , TE�� DISTRICT GROUP TVPE fIRE PROCESSED BV O ' TICE TO APPLICANT: If, after making this Certificate of f Q ENGINEER NO. -1 4 �emprion, you should become subject to the Workers' J CONST. ZO f"' � ..ompensation provisions of the Labor Coda,you must forth- qODRE55 3990 Westerly Pl ace #17� /J ,�3 �� � t/'�` GJ � with comply with such pror�sions or th�s permit shall be ` �1- � deemed revoked. TE�� S7anSnCn�CinSSiFlcaTioN APT. - CONDO. CfA � CONTRACTOR B NO. � � � LICENSED CONTRACTORS DECLARAT�ON �i�. CiA55 NO. DWELL.UNITS � I hereby affirm ihot I am licensed under provisions of Chapter 9 ADDRE55 NO. � (commencing with Seclion 7000)of Division 3 of the Business and ��� SEWER MAP � Professions Code,and my license is in full force and effect. CiTv C1n55 B BK � VAlIDATION � 6 SI�ZEFt_ �STORIOES Z F MILOIES 1 CONEK License Num6er 409610 Lic.Class k � YALUATION DESCRIPTION OF WORK NEW COnlla[�of ��Q Dofe ADp � s ' i �I am ezempt under Sec SFR � ALTER � ^ R 8.8P.C.for fhis reason USE OF R REPAIR � 3 J1��•� ��� .- I /i���P j Date: DEMOL � - �, g EXISTING BLDG. ❑ . � u;%� � Signature APPLICAM TEL. FINAL � OWNER-BUILDER DECLARATION PRINT) Bramalea Cal if. No.850-1001 / e�, UATE .�.,L 1/�� i ,G��5.y� � 1 hereby offirm�hat I om ezempt from ihe Comroaor's License qDDRE55 3151 Ai rwa AV2. #N �OStd Me sa � ,: y��_ Law for Ihe following reasan(Seclion 70.31.5, Business and FINAL �( ��� �.`�,�. ,�,� � Professions Code): PRE EN BY /,��.��.c.�-✓" i � euuoiN� r:;j c g_�7 - I, os owner of 1F�e property, or my employees with ADDftEss � � wages as their sole compensation,will do the work and � the structure is not intended or offered for sale(Section LOCAUTY 7044,8usiness and Professions Cade). nnOVWG TEt. ! � I,os owner of ihe praperfy,am ezdusively wntracting CONTRAQOR NO. with licensed contracrors to consiruct the projecr(Sec- .0 � � tion 7044,Business and Professions Code�. /+D�RESS - ����i � CONSTRUCTION LENDING AGENCY REQUiRED TOTA�SETBACK F � � SETBACK �ARD HWY PROP.LWE WIDTH .�a a a e s I here6y affirm that ihere is a consiruction lending agency for FRONT the performance of rhe work foi which this permi�is issued P.�. ) ��]f]J,J Q ! (Sea 3097,Civ.C.). 9oE � i Toronto Dominion Bank P` s�7550G'� I Lender's Name � 9 San Franci sco Cal if. - � '� �o�Re{ � ��'",2 g��'7 ' lender's Address � P.0 Fee$ Permit Fea , 3 I certify ihat I have read ihis application and state fhat ihe ]rj.00 Issuance Feu 10.rJ� LDMA P/C fl above InformoNpn is correcf.I agree to comply with all County Investigotion Fae ordinances and State I ws relating to building construcfion, To�al Fee ��.�� LDMA Perm.N and hereby au� ori e eprese iative of�his County to enter � � upon t ov me ti ned pr p �ty ar inspectio porp-es. � . 1 � � '�� �+�� SEE REVERSE FOR EXPLANATORY IANGUAGE . ! � Si nature o+Applimm or Agenl �pote , � � �.. ...... ..... . _ .. _. . � -- . ,.. ...:.. _ - - -- --_ ...� _. _._ ,. ... _, ... _... _ .. .. _ . . . t� �, - : � ;t � � . , : . � � � � ' ' + �_� '' � $ �� � � � � ! � . ��' � ! ; ` � : � - � i ' ° ' _ '_ ? � � � ' "�` f � .. �" ? � � � � .. � '.' ^. � � '� �) � - � E � �. , _ 4 I : . � { 1 . � 3 I i� � 1 i ' � � i '? � � 1 I i o � i ' . . �� f e aM �N '. � � , - � - , � ; • `� '� :x � i � z ' ; . � - I ' , �s+ � ;j � � 9 S `� } _ _ f { ' �' ,„ � i � � ° � � , '" � � � ' � � \'�C7 � � � t � �� , a :G ; i s i { ���y� � � i ! - i �� � � , ' i� � � a : i .., w I � ' t. � ? � - j � • I , 3 • _ . � � � � . j f _ , �. 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