HomeMy WebLinkAbout0938A 0939A (5) WORKERS'COMPENSATION DECLARATION � �"�" ` "� --�-. � 6 `
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�I hereby affirm ihaf I have a cerfifimte of..consenf to self A�PPLICA���ON�� ���R���UILDING PE�RMIT
insore,or a certifimte of Workers'Compenwfion Insurance,
oi a certified copy thereof(Sec.3800;�Lab.C.)' � ����' '� �� -��� � �� �V �� ������ �"
6TWETX799� Hartford Grou COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. ompany p � � � l
� certified copy is he�eby Pumished. FOR APPLICANT TO FILL 1N qpoeEss �!�9
� Certified copy is filed with the rounty buil�ing inspeo- BUILDWG ` ' �
ro�departmeM. ADDRE55 1189 South Crestbraok Court
Date�""�1UApplicont P uTv Diamond Bar z,P �oca��rv
CERTIFICATE OF EXEMPTION FROM'WORKERS' NO.OF BL�GS. NEAREST �
COMPENSATION INSURANCE SiZE OF LOT NOW ON LOT CRO55 5T.
(This section need not be completed if the permit is for one TRaQ 4'2568 'gLOCK LOT NO. S� ��� �`�ESSOR
hundred dollars($100)or less.) MAP BOOK PAGE PARCEL
TEL. yyy���nN
I certify thot in the performance of the work for which this DWNER �- BPaITIC�.�e Limi C� NO. �j�-� �� ��Zh� OP ���" � l! "..3� �
r SPECIAL d
permit is issued,I shpll not employ any person in any manner . A�DRE55 �'9 CONDITIONS 0
so os to become subject to�he Workers'Compensotion Laws. V
. . CITY ZIP p,'
Dote Applicqnt ARCHITECTOR TEL DISTRICT GROUP TYPE PIRE PRO(�SSE�BY o
�?ICE TO APPLICANT: If, affer makin �hio Certifimte of u
.npfion, you should become subjec� fo ihe Wo�kers' ENGINEER Ar m B $ Illdll N0� �IrJ �� CON'�'S�T. �E
l:ompensation provisions of the Labor Cade,you must forth- qDDRE55 1 tE �]� �� �-3 � f 6
with comply with such provisions or this permif shall be ' TEI.. STATISTICAL QASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. _ f
LICENSED CONTRACTORS DECLARATION ��C. CLA55 NO. � DWELL UNITS�
1 hereby affirm thot I om licensed under provisions of Chapter 9 .4DDRESS � �}^ NO.
(commencing with$ection 7000)af Division 3 of the Business and ��� SEWER MAP
Professions Code,"ond my license is in full force ond effect. CI7V Costa Mesa �Ca CLASS B eK P� VALIDAiION
54.FT. NO.OF NO.OF CHECK
LicenseNumber 409610 �;�.aa�s_ _ B s�ZE 1 84 STORIES Z FAMILIES � o"E VAWATION �:
DESCRIPTION OF WORK NEW f�-.y7 �-U /-.��G H
Comracio� Rramal aa Ca 1 i f Dpte Yy S I �
❑ . . . ADD L� LD�' � , c c �a �•L I '
I am exempt under Sec. � �
ALTER
B.&P.C.for ihfs reason REPAiR � S I °'.`;�2(;.�s I
USE OF '
/([�J�TQ' EXISTING BLDG. NDI'12 DEMOL ❑ � =�C t;,�! i
5 1 ' 1' / APPLI�'ANT TEL `
PRINT) BY'uCe L. Abbey No. 850-1001 F�NA� 9 �?-:.;:(;-;�b
� O ER-BULLDER DECLARATION � .. . DATE �„?'Pi�
I hereby affirm tAof I am exempt from ihe Coniractor's License qDDRE55 3 15 1 A i r w ay A v e.� N, Cos ta Mesa FINAL-�
law for fhe following reason(Section 7031.5, Business and / �
Professions Code): -�� PRE EM BY �«��L-
„zy-�} BUILDING
� I, as owner of the property, or my employees with ADDRESS. .
ages as fheir sole compensation,will do ihe work and � ' .-_Q�1 J S�_���.
ihe siructure is not intended or offered for sale(Section LOCALITY
7044,Business and Professions Code). MOVING TE�� . ,.; � . �.+ e � j
� I,as owner of the property,am exclusively[ontracting CONTRACTOR NO.
with licensed contractors to construci the projeci(Ser � °�=o-��i���
tion 7044,Business and Professions Code). nooRE55
CONSTRUCTION LENDING AGENCY� - �Qgq�� YARD HWY- T�TApROTPLINE WIDTH , . s �J��'�'`1"1,
I hereby affirm}hat fhere is a consfruction lending agency for fRON7 ' '
ihe performance of the work for which this permit is issued v.L � ��'�G���
(Sec.3097,Civ.C.). SIDE '
Toronto Dominion Bank P`
Lender's Nome -
- 144 Sansome St., Su i te 700 � �/ 5-��-� �DMA Ref.N
- Lender's Address . P.0 Fee$ �r 7I � Permit Fee '
I cerlify}hat I have read this application and state ihat ihe � �'�'f� Issuance Fee `� ry� tOMA P/C#
� above information is corretl.I agree to comply with all Counry Inves��gor�on Fee �.j �
� ocdinances and State laws relating ro building consiruction, 7ota1 Fee � l�� LDMA Perm.#
and hereby authorize represenfa�ives of ihis County to enier
s opon the above-mention%d prop rt for inspection purposes. ��„� •�1 -�
C __����--=J-� `�—�—�� _ . .. �:7C� .. .
SEEREVERSEPOR EXPLANATORYIANGUAGE
Signarure of Appliconf or Agenl Date' '' ' " �-
� � PLANS TO APPLICANT INSPECTOR'S NOTES 0�1'NF.R-BUILDER DECLARATION
_ . I here6y affirm ihal�I om�exempt from ihe CoNracior's
To: Retumed ?r 7 License Law for the following reoson. (Sec. 7031.5)�
A roved �'"—<—..:7 ��P�lfr"�� t-`;Yif .?I1— �;aK�tr?
PP I3u.sattess and ProJesainas Code}A���cidy or rount��u:hlcG
No. Dote No. Dofe , reguires a permj(to onnstrur[,alter,improve,den:olrsh,
� nr rehair¢xy structrere,J�nor to its isruance,also reguires
, . , . the upplicunt fir.cucb permit tr file a aigned state�rxent
ebat he.is licensed pursuunt to tbepm�isions r f tbe Con-
, .. ' , ... . .. .. . . - � , tracfors License Lau•(Cbupter 9J(��ommencing u�it{i Sec-
. tJon 7000J of Udaisdon 3 n/tbe Basiness¢nd Prnj.c�-inn.c
� �� � Cude/nr thu[he r.r exempt tTierefroon nnd the basis Jor the
uReged exem)tinrs.Any oiolatinn nf Sectioa i032.5 hy
Required Oate Received . - � . anY pprica++t fnr a yermit sv.bjectr[he u/�plicarst to u civ�i!
Approvals or Approved aeaalty qJ not more tl an.f've fiu�dred do!lurs(Ej00/.J:
Ves No
� I,os owner of ihe properiy,or my employees wiih
Water Certificafe . . , wages os their sole compensation,wlll do Ihe work,ond
�he siruciure is not imended or offered for sale(Sec:7044) �
Heolth Deportmenr .. .... . . . . � Baslness and.Pr fessinns Cnde:7'Ge Contra<�tar's Licett,ae
],uu�doer not¢pply tn an ouner of properiti'ul�o fiurlds
Fire Department � nr improres thercon,und who does such wnrk himself nr
. tl rnugl� brs oa�n.ernplril�ees, prorrded that-sucb i� ,
Grading . Qrorements are noi ixdended or ofjercd fnr sale
� � � - .. . . . l�nu�ever,tbe bui(din�or rmprovensersa issnld u.�iblln n.ee
Geological year of rnmpletinn, the ou�ner-builder uul!har�e'tbe
� - fiurden f prncin�tl at be did not biaiGt nr impmve jnr
Pedestrian Protection - . , eFie purpnae f.vuleJ.
(Fence)(Canopy) • � � � �- ] I,os owner of the
property,om exclusively ronlrac-
. ., . ,,. -ling wilh licensed con!roctors�o constru,ci the project(Sec.
Spenal Inspection ' 7D44i Businois und Profea.eioas�Code: Tbe Cotttrnclnr's
(Conc.)(Masonry)(Weldingl , Licerue Law dnes nnt upply to an ou�ner of prn[�erty u�!n
fiuiWs or i»��rores tbere�n,and ud�n conlrucGs for sucl
Lot Droinage . , hr�g'ects with u contructor(>J limnxed pursuani tn tHe
Cnntrurtnr'.c Licer�.co 7,au�J. � �
Parking . . . .
�� I am esemp�under Sec. ,B.BP.C.for this
... . reason . . .
Date Owner
Appro�als Data inspecfor's SignWure _ .. � . . - INSPECTOR'S NOTES
Lo<ation— ....
(Setback&Yards) /- /[�
Foundaiions ' � � �-
Slab C'I ��"��' � '�
6
Frame .7`7(C /� %�
/ ,C
Energy Insulation � .. .
,j_�/.�i . . . . . . .
Lath/Drywol�-- � �
Inierior ;S/���-�
Larh--Exterlor 7/�,�� /� �
J 2
House Number—�- ' / � � — .
Correct&Posled �%�. v�,/;��ti-' .. ' -� "
Fino�—� _ . . .
Ente�yr on FraM -
F—C'��^ �� . . .
F�- Cfd" 2 7L�'z"� �' �