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HomeMy WebLinkAbout0431A 2350A ,;.r ut .,. .. ."_'.'_."." .._ _... _ - . ._ ._,_.. ... _ . - . : '._ ......'_...___ ._.__.. ... ....' ' WORKERS'COJalPENSATION DECLARATION ':.� �: ' ��: ''�" ^ � .'•..'. . :- �. '- ' . .., . ., . , . . ..... .. .._ . . . � �' .'.".- . - . . - .- __ . I hereby o��,�m;�a���o�a a�e.,�f,�o,a.o,�o�5e�„o 5e�f APPLICATION FOR �.BUILDING PERMIT� insu�e,or o cerfil:;ate or Workers'Compensoiion Insumnce, . br a certi�ied copy�!Mereoi(Sec.'3800.Lob.C.). ..,' .. . ...- -- . . . � . . . -- - ..-..- �_`- 1 Certified copy is hereby furnished. �- •• fOR APPIOICANT O FIOSrANGElES AooREu BUILDIDNG,AND S�OAFE��i�� � Policy No. Company . . . - . ' 1 . _ I o. , ., �.s�� ;� : � �� Cerhfied copy u filed wdh the tounry building inspec- �� eunDwG �/ Q � . � ��tiondepa�1m8a1.�. ... `.�. , - � ., . • . ADDRE55 'Y� �p/ �'�.�• �. �l aaL� � /�J . Dote,• � . . . ��Appllcam`�. � � . _ , �:,'� C�tt�/A�D�C.� E9T�'/� Z�a LOCntITY ! � • . .,,. �•�.. _,� �,�..., . . . '' CERTIFICATE OF EXEMPTION FROM WORKERS'�'�•'��`� - NO.OF BLDGS. /5�-G-� � NFAREST.. .�7 '�./ ... .... .. .... . _ _. . � - ' - COMPENSATION INSURANCE' � � - SIZE OF lOT NOW ON LOi (//�+ CROSS 5T. /Q�/�O�D /��� �-�/� � J .. .., ... . .,. . ... (This setlion need not be'completed if the'permit is(or one --- -- ASSESSOR_, - -- -` , ��' �� hondred dollors(3100)or less.) , , , . ; TRAC7 BLOCK LOT MqP BOOK ' PAGE� PARCEL I ... . .. .. : . ...... .� . � . _.. OWNER�� f'/�.� ....- NO., �'/'Tv� NE � /�I r� �fl USE LO �P I certify,that in the performance of the work for w�Ich`this /� �� � ; d � permif i5 issued,I Shall not empl y o� pers 'n on anner �� y� �+' /� � 3-- SPECIAI (._ ADDRESS I7 TG-/'��7ZJf�ZL p�+/7�/� l.�� CONDITIONS ��O so as to become�iubject to the oi rrs Co'mp a o Laws. � � � ' - � ' V � . .: , ... .... .. � . �. � . _. ._.. --- -.. _ - " -. _ . _ __.. _ �.._ � an -�(�/.t_L= --._ . . nv _�7'�lf_ � ;m ,.. -. , ; . �7ote 2 Appli[an ARCHITECTOR A � TEI. ' .DISTRICT... _GROUP,. ttPE_.• .,._ fIRE_ . PROCESSEDBY � �NOTICE'O� PPLICANT[ If,�aN r oking Ihis Certificate of ENGwEER /iSA ��/ /�.� NO. , Exemptiori,' yoo`should beco 'e'�sLb�ect to�tha Workers' "� CO�NST. �� � ZONE J:� C.� 8/yJEr.�t �d5%71 f'I��R �� - � v„' - �� p�, W Compensotion provislons of the lobor Code,yov mosl forth- qDDRE55 2(r�7 u �'y ' with.such rovisions or Ihis• ermit sholl ba �- ! with Comply p p " ' TEL ' STATISTICAL QASSIFICATION , � APT. CONDO. ' �-i Z deemed revoked:, � ,.,,. ' '.• • � . .;.. COMRACTOR NO. _.-.___ -_ - .--. - � . . . . ___ . . _� . . . ....� IICENSED CONTRACTORS DEQARATION•, . - �- - ---- �- �-- � - - ---- - - -uC. ! '-- � -� �u NO.� ��DWEtI.UNITS I he�eby offirm that I am licensed under provision:af Chapter 9 ADDRE55 NO. ��R�P ' (commencing with Section 7000)of�ivizion 3 of the 8usiness and . _.. .. ...-.-- -.-._'-- ' .... -- --'.. -LIC:.-...- �- --- � ' � ' � ' , i Professions Code,and my license is in(ull farce and ef(ed. CiTY M55 -� BK--- "'�:"� �'' �- � '��-' -� - -�VALIDATION� � , .. .,, .,. ., , ..�. ,. ,�,...:.., , � ., ..... .,. , . ,..�.,. . ., 5(�.FT. - NO.OF _ .. NO.OF CHECK � . . . .. .. . . . -.... \ . .. . litenSeNumher� ' � �" �lic:Class �� ' SIZE �� STORIES � FAMIUES ` ONE :�� , . . . . , .',,, �.. ., . . . ... . _.VAIUATION...-�'-- - -� -- � -- ---� � . Contl o�cRo�.. ....�, �. .. � ,. � • �. . � '��. ��....,.,., .... �ESCRIPTtOMOF WORK- UE.���D_____ NEW �-O }{ �, � , . ,.��. , .. ... D'ata ' _ Ap� � •= 1 Q `- � _�_sVT,E`/.�'b.P , ' ._._._. .�� .. 4 .... exempf under Set. - -'- ALTER � � �� � � �2 3 " . . . . ... � f .'."' .'_'__._ __'`_.___. _ .._.: B.BP.C.for fhis reason ___ REPAIR � � � oote:. .'. use oF DEMOI ❑ , . � ' I + •4&8 8 _ _ . . _... _ EKISTING BLOG. bFF��i � �� � ! „ " ___ _ � . . _ _� e • �" APPIICANT --y TEL. i 4�H�V --� � SnnaFiire -_ -.- - � � -- �—.._— NO. 7�'Z�IrD FINAL. . OWN R-BUtLDERDECLARATION ��M /'�'�� `i� ..DATE - -�� -. .... .;.--'- -O�D li'-.8.�]' -.._. : -�I hereby affirm tho�I am exempt from�ha CoMracbr's License ADDRE55 �Z ��T«��--�%���`f 27 � � -" " - Lvw for fhe following reaion(Sbttion 7031.5,Business and FIN , g '. ' ' ' , ._� . � ..ProfeSsionsCode): ��--..-...-� . _ . __...�.. ...... - --- eueSeNr . _ . .- -,-.� BUILDING � �� � � I, os owner of Ihe property, or_my employees with ADDRE55 " ' �' � ��'" - ; wage:astheirsolecompensation,willdotheworkand ��� . � � � i � the structure is not inlended or offered for sale�Saction ��"��Tr � - . • '' � � , . ' '-'-- '_. '---- 7044,Business and Ro(essions Code)r -- .... .... n�OvtNG - �� ----.._.._ .._ .. -iet--- . _ .. �... .-- ��------ � ---- - �- - - -._...._ � I,es owner oI the property,am exclusively coMracting CONTRACTOR NO. � �! `with licensed contrattors to-construct the projetl(Ser .-..-- ---- - ---�'-. ._..—.-� '-- - - '--"'"" � --`"-- -. ...---�--------�- -�-- ���------. ..__ ._. . ._._... . . fion 70dG,Bosiness and Professions Code). ADDRE55 ' ' � ., "_"_"__' REOUIREO IOTAL SETBACK fROM - . XI T. .. . " ""_'_ ' "_'_'- �--'_--'--.'-.' �- -...-Z.3 S�A--�- � IherebyaFfirm�ihaslhereis�aconsDlrlucfiornGlend�gogentyfor fRo i�K YARD�- HWV- pROP.LINE WiOiH i . ,_ .' '_ ' -��he performance�of the work for which this permit is issued -- p.t.--- - - �---- ---- -- . --.. .'-"-.._.... _....-.' ' ._-_--.---- -- .. ! ,..._ -.-'_$f-_°._' .' ._' �- _ , 0 (Sec.3097,Civ.C.). . SiDE . ( � ' °(��`d Q Q , � __'_ P.L ' '_ _ _ . _' ""'"' . . .. ...... .... ' _ .. .. _ ...___ ` ._ _ - __-___ . _. _._..'_' . . . . lender's Nama � n > c (;� � IDMA Ref.# ' , �G-� ..... ._._ .. ._......" '_ P.GFee E__ _ . . -.- Permit Fee__ _ � ' . ..... _ _ '_. . .._ .. . ._.. " ".. __ _.. . ... Lender's Addrcss �---y� ' � �(i?'-s�7 �� � .I certify that-I hava read ihis applimtion and stote that the ---.. .. . _. .- ----.. ....---- iu�„ca Fee.. U �1� �' IDMA�P/C M-�--"-'- '.: . '.... .�----�...- ... _ - ' . . � o e inf rmation' conect.I agree ro comp y with oll County Invevigmion Fee � - _ord nan e ond a1 laws.r�fting^to bni in construclion, . � � - - . ' __ . _._.. ._. ......._.. TotalFee..: . _•C�_V" ' IDMAPerm.X__ _._._" .". "_._._'..._.. . ,�: on he aulh rix rep esenta�ives of t is unty to enter . _up t ove- e io erty n pe ton purposes - • . _ _ _ . . ._ , _._ /J -' - - ----- - ---- - -'- -- --. -' " ' -." - - - � - ' - -- . � lO Z/�7 SFE REVERSE FOR EXPIANATONY IANGWGE : � �-- Signarure of Applicam or A ent__ - '. . Dote . . '_'_. _._.__ .. 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