HomeMy WebLinkAbout0896A 0897A (4) � . . . _ 6�.
WORKERS'COMPENSATION DECLARATION -� ' �
insureborafcertifcareof�WorkesrtCompens�ationensurancef A,PPLICAT.IO.N _FOR BI���L��I�tVG �PERMIT
or a certifie co ihereof(Sec.3800�Lab.C.) � � - ' � '
6�16J��fX799�? Hartford Group COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. ompany - '
� CerHfed copy is here6y fumished. FOR APPLICANT TO FILL IN BUILDWG � � _*Z"�` �1�-
A�DRE55 v'iw.rii�
� Certified copy is filed with the county building insper eUIIDING � � fl
�tai'on d�ejpartment. ADDRE55 1187 5auth Crestbr �J
oate D -t-v� Appllcanr ' ^•�- �v- arv Di amond Ba r z�a �ocnuTv
CERTIFICATE OF EXEMPTfON FROM WORKERS P � � �-- 40.OF BtDGS. NFAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CRO55 ST.
(This section need not 6e completed if the permit is for one 42568.i' -� nssessoR - �
.hundred dollars($100)or less.) TRAC7 - 6LOIX LOT NO. 62 MAp gpOK PAGE�� PARCEL
TEI. US ONE �+P t
OWNER' � NO. _ NO. I��'`� � F t �'�L�
i certify ihat in the perFormance of the work for which this �, SPECIAL d
permit is issued,I shall not employ ony person in ony manner ADDRE55 3151 al Y"Wd Ave. Sui te N �-v�0
so as ro become subject to rhe Workers'Compensation Laws. CONDITIONS Q
V
c�Tv Costa Mesa z�c 92626 �
Date Appliwnl ARCHItECT OR TE�� DISTRI�'f GROUP TYPE FIRE PROCESSED 8Y o
!^"710E TO APPLICANT: If, ofler making ihis Certificate of ENGINEER Aram Bass llld NO. - CO Z�yVE U
n tion, you should become sub�ect to ihe Workers' /� J�, �/�
Compensation provisions of ihe Labor Code,you musf forth- qpDRESS 399Q Westerl P� � 1 �U �,-�-3 Y ,�'"' � �
wiih comply wiih such provisions or this permit shall be ' ' ' ' 7EL STATISTICAL CLASSIFICATION APT. CONDO. y
deemed revoked. CONiRncrOR Bramal ea Cal i f No. - �q,,� ,�L� z
LICENSED CONTRACiORS DECLARATION -- LIC. CLA55 NO. vU OWELI.UNITS�L=
I hereby affirm ihat I am licensed under provisions of Chopter 9 A�DRESS 3151 Ai rwa Ave. N No. 40961 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business ond . LIC.
Professions Code,and my license is in full force and effect. CITV COSt M [1A55 BK � - VALIDATION
Sq.FT. NO.OF NO.OF, CHECK
License Number 4nA610 .� ���:c�a�� `. g � s�ze � STORIES Z FAMILI� ONE VALUATION , ''il R G,-'��i,
DESCRIPTI N OF WORK 3 NEW l
com�a��o. Rrama 1 aa CA�l f Date ADD ❑ S ! �� ' . ° " `�i
�1 om exempf under Sec. ALTER � ' �1�°„i C.C'�;i .
8.8P.C.for this reason N2W Constructi on REPAIR ❑ S - -
USE OF ❑ c d:'L'I���.�i:.:
DO1e' EXiSTiNG BLDG. NOYI DEMOL
ss ature " � A�pgANT7 Bruce L. Abbe No. 850-1001 F�NA� s 4�������
WNER-BUILDER DECLARATION �- . , . DA7E S L�� 7
I hereby affirm that I am ezempt from Ihe Coniractor's License .
Law for the Following reason(Section 7031.5,Business and P.DDRE55 FINAL
Professions Code): � - - Pae M BY -
f+r-� BUILDING
- I, as owner of the property, or my employees with ADDRESS _ , , _. . _ . .. .
==O C C�F,
wages as�heir sole<ompenwtion,will do the work and �OCALiTY '
the structure is not intended or offered for sale(Section ' }; o c a c x 1
� 7044,Business and Professions Codef.- �"�"' MOVING TEL , , �
CONTRACTOR NO.
1,as owner of ihe property,om exclusively contrading i�%4-�!'.�ij
with licensed coniractors to consrruct the project(Ser qDDRe55 �
tion 7044,8usiness and Professions Code). - o t�.<2(:�)[�? �
REQUIRED YARD HWY �OTAL SETBACK FR M XI T. .
CONSTRUCfION LENDWG AGENCY SE78ACK PROP.LWE WIDTN ��^y�. .
I hereby affirm thot ihere is a consfruction lending agency for FRONT ' U c`.',:_v J C
the performance of ihe work for which ihis permit is issued - P.L � - � � �
(Sec.3097,Civ.C.). SIDE ., -
Lender's Name
Toronto Oominion Bank P`
144 Sansome St. Sui te 700 ) �/� �/ � LDMA Ref.#
- lender's Address . � P.G Fee S OC P• •'v� Permit Fee 7� '
I certify that I hove read this appli<ation and staTe�hat ihe ��'� issuance Fee i d� �� LDMA P/C#
Q above information is mrrec7.I agree to mmply with oll County invesrigar�on Fee (� �[
ordinonces and Stare laws relating to 6uilding mnsiruction, Total Fee Q` T`�� L�MA Perm.#
and hereby authorize representotives of ihis Caunty to enfer , ,
m upon the above-meniioned property for inspection purposes. >P n_,r� �.�;
a �� �^, . 7_?i�•ai
��� SEE REYERSE FOR EXPLANATORY LANGUAG
Signature af Appii<anl or Agent Dote ' ' ' " - - � �
�
p _ _..
� PLANS TO APPLICANT INSPECTOR'S NOTES OW VER-BUILUF,R llECLARATION
I hereby affirm that I am exemp�from ihe Contractor's
To: Returned License Law for rhe folbwing reason. ;Sec. 7031-5)
Approved 13usiness und Proressions Code:Amy city or rnunty ubuL�
No. Da4e No. Dafe reguires u permit[o construct,ulteq empmve,dcmolia�h.
nr rcp�irany strncture,prior tn its issunnie,also require.c
� the upplecant for sucb perneii to file a sig�ed statement
thr�t be is licensed[ursaant tn t.�e�rovi;inns oJ tfie Con-
- , � � . trac tor:e I,icense Luw(CSapter 9�I(commerocin�u�it1�Soo-
. tinn 7000J�f Drui.��inn 3 oJ tbe Busrnea�s anJ Professinns
� CodeJ or tbut he is exempt therefrom und dhe bacix(nr fhe
all�ed exemption.Any viol�tion nf Section 70315 hy
Raquired Date Received . . �nl'�1f�licant fnr a p�„n:e s�hjects ah�appl=cane to u ci��i1
Approvols or Approved � penulty o/nnt more t!un feve hundresd dnllara(.6JOOf.J:
Yes No
-� - �- [ I,os owner of fhe property,or my employees with
Water Certificpte wages os their sole<ompensation,will do the work,ond
. the structure is not intended or offered for sale(Sec.7044)
Health Departmeni �- � . Business and Professioms CnJe:Tbe Contructor's Liccrn�e
I.au�dner nnt apj�lv dn un oa�nar of propert��a•bo builds
Fire Department . . or in�prnves tberaon,and u�bo does sucb u•ork GimselJor
. tb iugh hrs ourn empl�yees, Provided thha su��b "
Grading " prnvc�rnents are not intended or <ffered fnr xale
� . .. � . ... 1 n�uer�er,the firei[ding or i�rovement rs.eold witl rn nne
Geological � y¢ar oj completinn, d2e o¢vzer-bvilder wi71 has�e t5e
� burdcn nf prna�ittg tbat Le Jrd xot bazild or improi�e for
Pedesirion.Protecfion tl e/irerpa.ce o/.aaleJ.
(Fence)(Canapy) - -- '' '- � � � � r� I,osowne�of fhe property,am exdusively contrav
ring with licensed<ontmctors 10 mnstruct ihe project(Sec.
Speclal Inspectlan 70441 Busine.cc and Prnfessionx Cade: 7'he Contractor's
(Conc.)(Masonry)(Welding) I,icense Lau�does nn1 apply tn an nuvier nf property u�!o
bui/dc�r improres t1 vrvnn,anJ�:ho cnretructs jnr suih
Lot Drainage , projects witb a mntrartor(s/licensad parsuant tn tbe
Caxtractori Lrcex.ce I,au�/.
Porking
� I am eeempt under Sec ,B.&P.C.for Ihis
. . . ..... ............... .. . .. , .
reason
. �ate Owner
Approvals Date Inspector's Signature � " .
. .. . INSPECTOR'S NOTES
Lomtlon— _
(Setbock&Yords) �'/
Foundations ��� y` - ..
Slab � ��Zv� ._.. .
b -__Z�'f_
Frame .�,y?_S '�-- .
Energy Insulotion -�7.� S�� . �
J -
Laih:Drywall- � - - � � � � � � �
Intenor �-�f!'-�7 �
Lath—Exterior ?�,�� 6? � � .. .-..". . �
House Number�- i: , .
Correct 8 Posfed G �' � � ����
final- . . . . ,
Enter on Fronl
q'2CGF: .J._i:,'�� flr'� ... . .. . . . . ..
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