HomeMy WebLinkAbout0864A 0865A (4) . . . 6c�
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, WORKERS'COMPENSATION DECLARATION � � - � "
,. . "_. .. ... . . ,
. AP�LICAT�ON F�It..�BUI�� . �.
I hereby affirm ihot I hove a certifimte of wnsent..to self DII�G ��PERMIT �
insure.or o certifi<ate oP Workers'Compensation Insurance,
or a certified copy ihereof(Sec.3800,�ab.C.) [OUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo61WETX799�omPo�y Hartford Grouo - p
� Certi4ied copy is he�eby fo�nished. FOR APPLICANT TO FILL IN aooaess ,�/s� , �•�py�v �.�
OCertified copy is filed wi�h the county 6uilding inspec- gUiIDING 1�92 South Crestbrook Court ��
tion department. - ADDRESS
Date���� Applimnt I�__�� CiTV D�t�IT1OYIC) B�P ZIP . . ... LOCALITY . �
CERTIFICATE OF EXEMPTION PROM WORKERS' ' �- NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE ' � SiZE OF tOi P NOW ON LOT CROSS ST.
(This secliori'need not be completed if the permit'is for'one TRACT 42568 �B�ocK LOT NO. 6� � MqPSBOOk - PAGE PARCEL
hundred dollars($100)or less.) TE�
OWNER Bram � NO. � _ USE.ZONE M1�+P )�, }
I certify that in Ihe performance of ihe work for which this ��� NO. l
permit is iss�ed,I sholl not employ any person in any monner n SPECIAL a
so as to bemme subject to the Workeri Compensotion Laws. /+�DRESS 3151 Ai r v�-,) CONDITIONS �
CITY C Z�P CC
D�qte Applicant ARCHITECiOR TE�- OISTRICT GROUP TYPE FIRE PROCESSE�BV �
' TICE TO�APPLICANT: If, affer making Ihis Certificate of ENGweER NO.
nption, you sho�ld become subject to the Workers' ' ] �N� ZONE W
ll.ompensation provisions of the Labor Code,you must 4orth- A��RE55 3990 Westerl P�. SUl t2 �7� /v ��-� �� t�0�
wiih comply wifh wch provisions or this permi� shall be - - �' '-' , -" {E�,-'"' ""-�- -'-- STATISTICAL ClAS51FICATION � ' APT. CONDO. Z
deemed revoked, CONTRaCTOR Bramal ea Cdl�f No. 850-1001 aass rvo.�� DWELL.UNI75�
. UCENSED CONTRACTORS DECLARATION � � � �� � uC.
I hereby affirm that I am licensed under provisions of Chopter 9 ADDRE55 3151 Ql V" N�� SEWER MAP
(commencing with Section 7000)of�ivision 3 of the Business and LiC.
Professions Code,and my license is in fulfforce and effect CITY Costa�Mesa �CA CLA55 Q BK. pG. VALIDATION
54.FT. NO.OF NO.OF, CHECK —
License Number an4�i n Lic.Class B SIZE �44 STORIES 2. FAMILIES 1 ONE ;9[��-G.�=a.
PLAN 24 VALUAZION
DESCRI O WORK NEW ��P` �� �; P a � ���
Comrac+or Rramalaa falif oaie ADD � S 7f
�I am exempt under Sec. S 1 n � F A�TER � , i �'.t�1.-J l��C �
B.&P.C.for�his reason , N2W Construction__ REPA,R ❑ S c.::j Q j�'i�.
USE OF �
� Date!:d� - EXISTING BLDG. DEMOL
'S' 1� J .��' � `�'' APPLICANT TEl FINAL �;'��.�Y�.�
� OWNER-BUILDER DECLARATION PRINT Bruce L. Abbe No. 850-1 oare
I hereby offirm ihof I am exempi frvm ihe Coniroctor's License qDDRE55 3151 A1 PWd Ave., N COStd Mesa FINAL
Law for ihe following reason(Section 7031.5, Business ond
Professions Code): �� PRESENT BY
��� I, as owner of the property, or my employees with ADDR SS .. , . , _ .
wages as their sole compensation,will do ihe work and ' `:�Q��.j C�
ihe structure is not intended or offered for sale(Se<tion LOG4LITV
7044,Busin¢is ond Professions Code. MOVING ' TEI. 'a n e c
� I,as owner af ihe property,am ezclusively contracting CONTRACTOR NO. . ' �� • {' " ° t �
with licensed coniractors to constroct ihe�p�oject(Sec- i c;.�,�Q(;
tion 7044,Business ond Professions Code). ADDRE55
REQUIRED yqRD HWY 'T�Tp'���p'�K FRO 5T.
� 'CONSTRUCTION 1ENDING 6.GENCY --- ��- � 5E7 snCK PROP.LINE wioiH �° � t:G U.G 1;�_
1 hereby affirm that there is a construction lending agency for FRON7 '
the�performance of the work for which this permit is issued P.L �;%�,{Q.—v(;
�Sec.3097,Civ.C.). SIDE
P.L.
Lender'sName Toronto Dominion Bank
. F . �� L�MA Ref.#
144 Sansome St., Su i te 700 P.C.Fee s . � Pe•m��Fee � '
- lender's Address • y y
I cerrify that I hove read this appliwfion and sfafe 1 at the /..�o�y Inuan<e Fee ��'-'�� LDMA P/C#
¢ above information is wrrect.I ogree to comply with all County Invesr�gmion Fee -�
ordinances and State laws relating fo building constCuction, - To�al fee ���� IDMA Perm.#
and hereby authorize representotives of this County to enter ,
� upon the obo�e-mentioned property or inspection purposes. ,- I �
` �iP/Le.��e�-�� . . . �;_
SEE REVERSE FOR EXMANATORY IANGUAGE
� ignoNre ot Applicant or Ag t Date ' - ' - `�
. . .�.:n-.r.-v�a,a.�.:.r�..r.,...�.-�.r.._"_"-•,"---`c�_,.>...:-..-- -,__.,_........._w,.._^..•--.�,,._._.,.,._.....�K�,,.,.-:�-..�.-.e...............�...�-....__�._.__.--_____..q._,-._..�_�__T. .-
' PLANS TO APPLICANT INSPECTOR'S NOTES ON'NER-BUII.DER DECLARATIOA'
, I hereby affirm thal I om exempt from the Contracror's
TO: ReTurned License Law for ihe foilowing reason. (Sec 703L5?
Approved BwsEne.��s anJProfessions Code:Any city orcount��mhicb
No. Dofe No. Date . . reyreires a permit to mnstruct,alter,improre,demnlirlr,
rir repairany strudure,prinr tn i£c essssance,alsa reyuire.e
ebe appllcant j.,r such permit to file a srgned statement
tLat!e i.a ficensed pursuant to the provrsrnns of Cbe Con-
� _ � - . � � � � �tractnr's License l.ou�(Cbupter 9J(cornmencsng u�itb Sec-
tion?000/of Urvisrnn 3 nf rhe Busrwesx mnd ProJessdnns
� � � Cr deJ nr tbat l�e is exempt there�rom and tl e ba.eis jor t{e
alleged cxcmptiun.Atty violafinn ojSection 70j1.5 hP
Required Dofe Reeeived anV a�/�lieunt Jor�e permit svbjects tbe upfilie�axt tn u<z<�r!
Approvals or Approved penult.g�n(not»:ore tl an f've aundrE-d��,nar.,��ssoolJ:
Yes No
❑ �,as owner of the property,or my employees wiih
Water Certificate . . wages as their sole mmpensation,will do the work,ond
the srrucwre is no+in�ended or offered for sale(Sec.7044)
Heahh Deparlment . 13sssiness and Profrsssions Coder TAe Contracinr'.s I,ice�ue
I,rtu�doet nnt upply tn an nwner of proper{y ufio burlda�
Fire Deporimen� - . .. or improves thcreon,and u•Gn does.rucb u•ork bi»:self nr
t!rnugb bis nu�n emplol�ees, provided tha! suc6.•�-�-
Grading J�rpvements are nni ixtendad rm of/ered(nr salc
� �� � � ho:uet�er,tbebuildix,Korirn/rrovementusnldu�ithimnne
Geatogicol- y�ea> of cnmpdetion, tbe owxer-builder u•ill har�e the
� � � - fiurden of prorixg ibat he did nnt Auidd or fm(rnve j r
tLe ose o sole.
Pedesirian Protection - Pu fi f )
iFence)(Canopy) � � � ' .] 1,as owner qf ihe properfy,om ezclusively mnlroo-
' ting with licensed contractors to construct the pro�ec((Sec.
Special Inspection - 7044)Businesa axd Prnfessinns Code:'rb�Contradnr's
(Conc.)(Mosonry)(Welding) �.ic'ense I.uu•does nut appll'to an ouraer nf prnJ�ert�•u�hn
, - _ ' builds nr intproves lbemon,anrd u�hr�rontraels feir sv.cfi
Lot Droinage � � Qnle�ts mit1� a cnntructrr(sJ licens�ed pursuant ta Lhe
Cnntr�ctor's License L.au•J. - � .-
Parking , . . . . . , . .. . . _ .. .,. . .. �
..J I om exempr under Sec. ,B.&P.C.for ihis
reason._..�. . . .
�ate Owner
Approvols Dafe Inspector's Signature . - ' .- . - �. -� � INSPECTOR'S NOTES
Lomhon-
(Set6ack&Vords) ��� � �r^
Fcundations — � -
Slab �hF— 1 l-z — � F^ - . . . .. . . . ..
� -z l�✓
Frame �., . _ . � .
Energy Insulation � .- . . .. .
Lath/Drywall-- . .. ,. . • . .. . � ..
Interior
Lmh Exterior . . . .. .'� �
House Num6er - � . � . - .
Correct&Posted . �
Final-� . . . '
Enter on Front ' � �� '�
�✓� ��/��G '� �^ � , . . .