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HomeMy WebLinkAbout0924A 0925A . � msure,or a certificote of Workers� . . � -'._.Yl.- '-� . . -� '-'� -"'--� �'-'�. Y. .-" ... WORKERS'COMPENSATIONDECLARATION ,. �� . � ' '-"�---. ... _�., ._; ...-....- �--. - .-.--.-.._., ; .. . . S'. ... . ___ . . . -. I _.. ..._ _ _ . . - " •I.hereh a,t,m �hal.l have o�certif¢aie of,consent to,e,� qpp��CATION� FOR.BUILDING PERMIT� - �; 'Compenso�ion Insvronce, . or a ceitified copy thereof(Set:3800,Lab.C.� ' "'" " -� - - -- - � � ---- - - � . . PolicyNo61WETX799�om���lartford Group � COUNTY OF LOS ANGELES � BUILDING AND$AFETY �� .Certified co is hereb furnished.,� � BUILDING� ' � ❑ Py Y �'' FOR APPLICANT TO FILL IN AooREu 6,z pyt �i,.�y,,,�— �'""1���CeHified�mpy is filed with iha County 6uild ng'I`ipeo -�- gURD�NG , ��...tion iJ artm C' '�. . � , ' ' ' ' '' ADDRESS �� .�.,.- i ' ':��. . . , ... ' _ ._._ ._.... . . . . _ _.__.. _ � Date�AppliconY CITY LP ...-- LOCHLITV � � . �-CERTIFICATE OF EXEMPTION FR M ORKERS' `��- �-��' ----- - --� ��----- -NO.OF BLDGS: �-�-�--- � � NEqaeSi....._. _ ._,. .___ ...__� .. . �- . __.—.. .__ ....�.. .. • � � ��� � COMPENSATION INSURANCE'- •� �- 5¢E OF LOT � nIOW ON LOT CROSS ST., � � . .. ., .. . i : (Thfs�secfion'need no�be compleied if 1he permir is forona �--- -�----- -- - ----- �-. . _. . ...�J ASSESSOR__.,. _ ��--�� ��- . . • hundred dollon($100)or less.) -. , � TRACT 42568��J BIOCK lOT NO. Mqp eOpg'`-� PAGE�� PARCEL �.,. , ' . .,...� .. _.._ _ OWNER' '_ '' -.."_'NO. gggZO E MAP . � I cert fy_�hot m the performance of the work for whicFi thn � � - � //� p�p ' � f�t-3 . � L U N permit is issued�1 shail nol employ any person in ony manner ...._. ADDRE55 -3�5�._A71"WO,Y.AV2. SUl te-N��-�-� � � - � �� �D � � SffC�A�-` "" - -�-"-- - � -. .._' I 'r ,a, so as�to becoma subject to ihe Workers Compensahon laws. � " �D C7 CONDITIONS � � Q Dale-, ,,,.. .�,...-AppLcant: . .. . .. .. . ..., . _... pN-.._ .-- COStd-.� ....'ZIP--- - -- -.. . . . _. �-- -_. _ __ .. ._. .__ .'OC . . _ ' : ... ... . `�7iCE�TO APPLICANT: If, afler�moking fhis CertifiEaie of ARCHITECT OR � TEL. _D6TRICT.._ GROUP TYPE :.__ .__. FIRE. . . PROCESSED BY 0 I . ENGMEER NO. ---' ��- �prion,'yov�should become iubject to�the Workers' "� J� CONST ZONE l.ompensa�lon provisions of the Lahor Code,you must forth- /" 2� li"^ ' �uVi A�DRE55 ' ' __._'._' ' .. . _.. . _. ._ ,� with tomply wiih such-provisians ar this permil sholl be -��-���-- deemed revoked: ,. . -. . . � . ,.�,:..� � � �• ; STnnSnCa�CIASSiFlCATiON ; � APT. CONDO. � � � � COMRACTOR ' NO. � . y� LICENSEDCONTRACTORSDECIARATION�...� . �. .. .. _. ...--._.---_._ __ . . . :-L�C.. .. . �Qp,55�N0.-..�-� DWELLUNiTS�L ... . _ .. -. - _ .Z I hareby affirm ihat i am licensed under provisions oi Chapter 9 nDDeE55 � NO. (commencing with Sectian 700�)of Divizion 3 0�the Business ond ,. • � SEWER NJ1V . . . . ...'-" . .._. _._UC.- .__ _.._, . Professions Cade,end my license is in full force and�effeU. ��ry Costa Mesa� CA ttqu--B� _- -_. ._ _.. ..... .... : .____ __ [. . . .. ... ... . . . . SQ.FT. _ NO.OF .. _ '..NO.OF'.. � � � ..N VAUDATIO li[en3e Number CHECK BK' �'' � . l � __"'" -409610 � ` i�� Closs � B��' S12E STORIES FAMIUES ONE , , - . V ` . Bramal ea Cal i f Date , . ' DESCRIFTION OF WpRK'' ._ �/ _. _� N�y_ � . `O _.. A UATION . _ _ �_ Coniractor s �S � 9 2 4 q . . ' .. . . -� ADD . � ❑I am exempt under Set. . . ., . ' . -'--'-' ALTER � .. .��e • • •2� , 8.8P.C.for Ihis�eo5on �.�.�: ,... . • REPAIR . -..f.__. _.. _ , .._.. !._ . _.____ .. _ .. . _ :_: ..._ _. __ . _ __. .__...Da1 USE OF � , '�, � ^3 8��� � . EXiSTING BLDG. NO�1EE OEMOL ❑ ' . ...'.. ....__-.-.,., }..- . -� -Signature ` . '�' � /+PPLICANT TE�. FINAL . e "J� I.�..�1��.. O ER•BUILDER OECIARATION � PRWT Geor Vedel l NO. - � _' , � � _---. _ ._. .._ . ,� _. . �-I hereby affirm t6at 1 am eKempt from tha Contmctor's license - � - �.-- - - - - -- - ����"��� '�� �' ��'�'�. � ��b-�� law for tha lollowing re5son��(Sedion 7031.5,Business and A�DRE55 3151 Airwa AV2. #� COStd Mesa FINAL� '' " - � � - � � ' - � . ,_ .. . ..... ._._.-_..'_-.......__....., r . . .... ._ . _. `"Proiessions"Coda]:' - .... .. vrtE Ni "�-g � " . .. .... - . - � .� . �'� eUILDING � ��- I,as owner of Ihe property, or my employees with ADDRE55 � � . . ___._.. . . �_.._� wages as ihei�sole compenwfion,will do Iha work ond - � � � the struc�ure Is not inlended or ofiered for sala(Section ����TY ' ' - � -�Q 2 5 Q �7044;Buslnes5and RofessionsCode):..-- .. ... ... --- MOVING"'� ----.--.. . .. -.. --- - ...TEL.... .--- -- - --.._ . .-._. . .. ... . CONTRAROR NO. `;,�- �("i 1�.e • • a �'�. . i,as owner of tha property,am e.dusively contracting �'� .\ � -�' with licensed contracfors ro constrott 1he pro�ect(Sec---�-�- -'--...... _-.---.. -....--- � - - ------�--- ---..- �--�--'-- ..-..__.._._.._. . . _ , . , t J, - ' . fion 7044,Business and%ofessions Code). ADORE55 ' ��° .O Q . . ..._. REOUIRED. fOiAlSEiBAIX M.. %I ......_..' .., r.i-�_ r,_: -"�CONSTRUCTION LENDING AGENCY"--" ��� -"" ' - "YARD-� -HWY� '- ' � SET BACK PROP.LINE WIDTM� ... ...... .- '--'-'-'.... _..._. .. . . s �ii v I�G 7 c'..� I hereby affirm�hat 1he�e is a consrruction lending a9ency for fRONi • .-�he perlormance of the�work forwhich this permit is issued - -.. ...p.l:.... _. .-..-.. —. . _--- -........-.... --.... - --.—. ...__.... _.. ._.__._.�.._- -.......I.. Q . �. . . C2�i`U6---� ($et.3097,Civ.C.). SIDE - _ _.__ ..._.. ._ . ._ P.L . . .... _. _. _ ..__.... . _ i ..._..'_ _'_'. . .... ._._ � ._ Lender's Name Toronto Dominion Bank-- — ___._.._''---: 144 Sansome St.�.SU1 t2.JOO �orM eef.N ! --""" - P.C.FeeE- � � .. . .. �.���.-.-- PermirFee- �.- lender'sAddres . . . ..- \ . � . - -� -I ' --- . _ ._... -I certify thm I hove read this opplicet on and state thal the _ _ .__.. . _...�:I71 �6-.� ' � : c �.�." � ���� .__. IssuonceFee-.�._ _. " .--"' L�MAP/LN . '.... '__ ..' _ _ _... _. ......_. _: . above informa�ian is mnec�.I agree to comply with oll Counly in�eargo��on Fee ' ���� _ordlnances and Stole lows relating to 6uilding construttion, � �p�'�. �l � � . . ._..,.„ �� . ..__ .___._'. _....._.__...._.' To+alFee-. . , IDMP.�Perm.M -.�........ .._..- . . ..�- . .. and he eby authorize representatives of this County�o enter �� � -- -- �-- � � _upon� abova-m n�ion d roperty for i spection purposes. � � - �/� _ _ __— ---- ------ --- -__ - 3 .. . _.. ....- — - - _.. u,� ( _. ... .. _ i lJ'�` � SEE REVERSE FOR EXPLANATORY UNGUAGE � � � ' . , ... ._. 9n' e .ApplicontorA e� Date..' ... _ . ..'"_'...."" _'_' _ '.... .�....._ ..._._._......_.. � _...._..._. ...... .�..'_' '__ ' . .. ..._.. ___. 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