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HomeMy WebLinkAbout0846A 0847A .,. - -�-- ------- .___....__�_-----..-------�---.._- --- --�-------------._. .._. ... .. --------- ---_... . � WORKERS'COMPENSATION DECLARAIION � ��-"'�' -"'ti'=�� � �'."- ': • � : !" .. �.�� .. .. ,. . . ...�.� ; .._._ ...,_. . � .. • � ' . . � h°,ebY o"�'m,ha,� ho�e a�e"�`,�o'e o`°o�,e°,'o=°�' -....APPLICATION_ FOR-:,BUILDING PERMIT�_____� , inwre,or o certi(icoie of Workers'Compensotion Insurance, . ___. _.__.-_- '--------'- . ..�.. _ ---. ........ _. _.. --- � - . .... or a cerrited copy t ereo �Sec.3800,lob.C.) `" COUNTY OF LOS ANGELES BUILDING�AND SAFETY _ -. PolicyN�11WETX7q9�Company HelPi'fON(� GPOIID -� - , BUILDING � � Certified copy is hereby furnished. .i FOR APPLICANT TO FILL,IN � ADDRE55 6 „Z . �� Certified topy'is filed uvith tHe counry building inspec- '� ' � euaDiNG �r� � �`� fion deportmenl. . -��� ADDRE55 .. . . .��. �.. ,...'�''.n.•��. __.. . _-_._..__.__.__._.'.',.______..�_. _.. _____.._..__... ._.._ Date�_Applicant GTY ZIP �pUUN � - �� CERTIFICATEOFEXEMPTIONFROMWORKERS'..'.., ..... .. .-_..._... . . .-'-'.._..--._.--'-NO:OFBLDGS.-..-- .-. . '. NEAREST__.__.._.�._..... ...._..,..."' -_-. .....__...'.'.-_-_ '-- � - � • -�COMPENSATION INSURANCE�•� -- • . srze oF�Oi / NOW ON LOT � CRO55 ST... - . . , .,,,•.. . (This sedion need not be minpleted if the permil-is for one -- � ASSESSOR.. ,�----- - -- •-���� . . . . . ..." ____.. . .,. �. hundred doliars(5100)or.less.).,, . TRACT �\� Bl0[K lOT NO. �1 Mqp gOOK� ' � PAGE� PARCEL _ . . _ . ... , .�:�..: . . .__ " _ .. . ._.'_ ' TEL MqP � _ $� �E I certify thal in the performance of the work for ��ich this ��E NO - ��- pp /(- � ��� '�, I permil is issued,I shall not employ any person in any manner ' ' a__ SVECIAL ������ --- � � �--�--� -' - �-0- - so as to b�ecome su6jeU to the Workers'ComPensat�on Laws. nooRes�151..Airway_Ave..-Suite. N_ ..___. _. • .�f�,�� CONDITIONS ; . . . u oa�e , . :,aaai��a�t. � : '. . __ arr CoStd 61e5a CA. _.ziv_92626 - -- o�sre�cr . cRouc __ , ' - .. - m — -� • ARCHI1EC70R � TEt. � 7ypE FIRE__ PROCESSEDBY.. '� �ICE TO APPLICANT: If after making this-Cenifitate Of ENGINEER N0� � CON�Y�f ZONE nption,`.you shovld become sub�ect��to'the-Workers' �-�-- J '�/ '�/-I. - ,!, a �ompensation provisions cf thc Lcbor Codc,�you must fcrth- qoDRE55 l t 1 � � � � ---" - - ��Ji -�� wilh•comply•wilh such provisions or thiz permit shall be �-�..- � TEt. � S7ATISTIGAL ClASSIFlGATION APT. CON00: � f Z deemed revoked. . ���.�. , ;�. . �. ,.- , �. �ONTRACTOR � NO- -]. 1 _ /}7� � _ .__ . __'.' � i CtA55 NO. `�✓ DWEIL UNITS LICENSEDCONTRACTORSDEQARATION... ,.`.� --- -------. .._..;.... ._......-.. . -tIC: --�- --. . � . I hereby aifirm rhal I am�itensed under provisions of Chapter 9 ADDRE55 151-Ai rwa Ave. N No.409610 ( g n 7000)of Division 3 of the Busmess and __..._ __.__ ..._.:___LIC. .....-... ._ . ..��'`'�R rn.4P _ � � - • � , Professeons Codehand�my licensa is in full force and effect. ��Ty Costa�Mesa�; CA� ' cwss B � - "� "" " '�� �� , -��- -VALIDATION-�- � . .. �.. .�. .� . .�. , 50.Fi. NO.OF � NO.OF CHEIX � � BK. PG. R license Number 409610 � � i,����s ' �� ��� SIZE � � � � STORIES �� FAMILIES � ONE-�. . , . i�o . . . �� y •21 . .. .. . . . . . . .� . '. . ..,. __—_ �ESCRIP �OF W�RK"—"'. �_" NEW- � . A _ . . . _ ' '_ . . ..,. LUATION . , � : � ° •� - _ -- s f0! 7do � Comractor Rramal ea f.al i f Da�e l � •J`2 Q 4� ' .Sin le_.Famil _Residence__.___ ^oo p ❑I am exempt under Sec. '�., r� -'- . . .. :.... . .�_.. AITER � e o J C C�.��-'�.��c*.��. . . _' '...__' ; �8.8P.C.for this�eoson .. ._ NeW Constructi on REvniR-❑ �;" ����' � - - � - � - " ' - � -�-� � .._ . _ _._ . _ -- oa�e:- _ use oF oer,�o� � ' O L�.1 9-8 6 . � . EXISTINGBLDG. �� - - -- - - - - - � ��j�'LL(�E'� �—-....... APPLICANT TEI. � -SignOfVre ` PRINT) NO. ' FINAL � OWNER-BUILDERDECLARATION -_ - . _._.. ... .. .. ..... .. ..... ' --�DATE -�. Z3 �� . . . - .. -.---- -.. -I hereby affirm that I am exempt from the Comractor's License qDDRESS 1 1 Al l'Wd AV@. N Costa Mesa � � - � � Law for the fol�owing reason�(Sectian 7031.5,Buziness ond � flNAL -� �"' ��� " � � � .-Professions�Code):__ ._. ..._. .__ _._.. . . ....._. .-_. vue r, . . sy . ..,.-�� � --.. �... .;0£L 7�{ � ^ I, os owner of the ro e or m em lo aes with qoo��eSS � � " �./ wages as�heir sole tompensafion,w II do the work ond ..._ .. . . . .--- .- .�. _; _ - . .....�.; __ri• s`e. • �-�-_ ihe siructure is not intended or o{fered for sala(Settion ����TY ' ",~ %}' � °5[G�i�Q_Q i _ . ...7044;Basiness and Professions Code). -_.._..._ _ _.'..'_ MOVING' .'."'...___.. ..' '._".__."_iEL:_' _'_..___...._.. ,... __.. _._•� . __. :.. _. ._ _ . . . _ . _.._ ❑ CONTRACfOR NO. - ' �. .. . � " � r I,as owner of the properfy,am exclusively mnhacting ' � � ' . �� � °:i�9�v�.i� -with licrosed contractors to�mnshuct ihe projecf(Seo -�- �� -� -�--- -���-- --- � --'--- -�--�--��" --���� -� �- ` ' -- " ADORE55 tion 70d4,Business and Professions Code). ' '� .: . ; � ! ��,� �j-4�,C' � . ... . .. . .RE�UIRED_.. - . iOTALSETBACKFROM__ XIT.. _._. . ..._... .. . . . �._-: _.. . .. _-.._. _ CONSTRUCTION LENDING AGENCY � � � SET BACK YARD- NWY� "- pROP.IINE WIDTH . � I he.eby aHirm that there is a consfraction lending agency for pgoNT � - . ' ' --" '� ..the performente of the-work forwhich Ihis permie is�issued -._. . -�-P.l.�--��-- -�----"�----- '�--"��----.-.._---_.__ _ _-- -.___ __ ----_.= � -_ - .'.--_-- '. �, - - _._.--._'_�--,-: ($e[.3097,Civ.C.). SIDE � - � , ....__ . .. ..._... . � _ .. . P.l._ ... " ' ' _ . . _ . ' _. _. _... ... .. _ .. .. ._.. '_._. LendernNameToronto�Dom�n�on BC h}--"--" 2p �n -� - � � � �����--� ��" ..._ ___ . _. �QII fl'dll$1,SC�t�r.F1U1741 ' .___ P:C.-FeeS - • �I - PermitFee...SdO��]�-.i IDMARef.M . ' . .. . . _ lender's Address s ��) ���. ._I tertify.thot 1 hove read ihis.application.and.sfale.thot the . ___ ,(�y�f.._..7���_.- Iauonco-Fee-._..../v�"-----' IDMA P/C M�.__ -.,�.. , �.1.... .. �. � . ..: _ _. above Information is correct.1 agrea to comply wilh all County Invnr�goeon Fee �(��(,' , �-�� ordinances and State laws relating lo building tonsVuttion, To+ol Fee----- "`f"1-'� ' �IDMA verm.k -- - - � �� ' . "'-'... _ .. _ ... _. _ _ ._ . . ... . .. _ .. .. and hereby ouihoriza represenlatives of this County�o enter � opon tha obove-meMio ed propert for inspechon purposes. . �p�� . (ti_�_ �+- . . . . _ . . _. . . __..._.__ .�. _ ... ___. . __... - -.-"-.. ._ �� _- ' -"" -'. _ ... . .._ . ._ . . d vl�F ��C�.�j(�p SEE REVERSE FOR E%PUNATORY LANGUAGE , I -.\ � _f_v_r �SignalureolApplicanrorAgent.- .-.--- � Dote-� - . . . ..� • . -. . -,. --' ' . . -. .. . � ... . . . ... ...._. __..... .__.. - ' � •�i � T O O � � 7 T Vf � N� _O .Or ..n�. ^�_ _�. ..�' ..T_ '2_ ��. 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