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HomeMy WebLinkAbout0804A 0805A . . : . . . . . ___ _._... __..-----�--- - WORKERS'COMPENSATION DECIARATION ; :..: ,� ,;,,... �- �..... --- _._,___ ._"_. ._ ._. - .. .--,, _'---.___.. . .___._. ._.. l _.__ __._ � � ;5 .. , . . _.. . . _, . .,. ____ _ I hereby aiLrm that� �a�e-o�e,,,,,�a,e��of.�o�5e�;-,o,e,f -qpp��CATION-�FOR-,;BUrLDING� PERMIT � , �insure,-or a-certifimte of Workers'Compensation Insurance or o certified copy thereof(Sec.3800,lob.C:)� �� --' --�--- - � � �- � ---- �- � � --� �� .� . .__ ___.. .. aol�cyNd1WFTX79A3comPo�y_Hartfo'rd Grouo COUNTY OF LOS ANGELES i BUILDING.AND SAFETY ,, � �: _ __. -_ _ - - - _ ,: Certified to is hereb fumished. � BUILDING ; � � ! � PY Y " ' FOR APPLICANT TO FILL IN 0 7 , �Cartified topy is file8 wilh the couniy building inspeo- '"�"--�' BunDiNG V � ' ADDRESS �'�tion departmenfi'� ' �• . � --�� ���� � ADDRESS 1073 South Lon V1 eW �� � � �,. ' , ' ..,'•.,. . _.i� ..,�.� , ;: __,_ _ �. ....,.. . .__' "'__'__"_.. .___ -"' __.."__- _ - _'_-_.! ' D'ate7-Zs$6 Applicam. UTV Diamond Bar LP � ip�ALIN '�`� 'GERTIFICATE OF EXEMPTION FROM WORKERS' ��� -" "' '�""'---"�""' ' "'-"NO.OF BLOGS. -- - ---� •; NEARESL.____ � , J . .._..."_'_'_'_'�._..i___... __....._.__._ �... . '' � "�"�� COMPENSATION INSURANCE � �'�� -. . SIZE OF lOT NOw ON LOT % � CROSS ST. � :....,..•� ' � (ihii3edion'need noi ba complefed if ihe permit is for one �--- --��--- � -��-� ---�----� �-- -.5 ./.___� ASSESSOR � --�-- � � � �� �:- � hundred dollars(SI00)or less.),.. � . TRA� 4256 BLOCK LOT NO. MqP BODK'�'� � � PAGE PARCEI . . . � � . . TEL _ .. Y. P � . . .. .�... . . . .�- OWNER. _ . (� _.....'NO.SSO-lOOl_: U ZO E MAP 1 ce�tif"that in tha erformance�af the wark for which this �� NO' . �� 3 / ,} I permi�is issued,I shall nol employ ony person in 6ny manner A�REu.3151-Ai rwa -�Ave.� Sui te-N -�----- ��do^ `�ECIAI � - � -��- - � -�- -- --�0. so as to bemme sub'ec1 to the Workers'Compensalion Lows. � � U CONDITIONS ' ' ;Q _ ..-. .. .. . . . ..,.. . . . . . ; V _._.. .__'__'_ ._ .... . . . ��TY___ Costa_Mesa CA.____ z�P.92626_...._._. —- Da1e'� '. . APPlimnl�... . , ., . .� _._' ' , . . .'R' • ARCHITECT OR ' TEI. ICE TO APPLICANT: If oiler makmg'this'Certificole of • D6TRICT_ GROUP_ TYPE__ FIRE PROCESSEDBY.. �nplian, yov should become subjecf to'Ihe�Wo�kers' ---- ENGMEER NO.J�jZ-I8E4 !1 - CONS ZONE ���j I Compensafion provlsions of fhe Labor Code,you musl(orlh- � • ' Iv � � 'W with mm I with:sucb rovisions or�Ihis AooRess 3990 Westerl Pl ace SU1 te 1]Q � ! �....L'... .._. �•3. _.__ ��_ . . _. . __..._. . �y p y p permN shall 6e -�����- r deemed revoked.. ;, � _ .,� �oNren[toe Bramal ea Ca��I . NO.SSO�IOO1 , STATISTICA�ClA$$IAGTION � L APT. CONDp. LICENSED CONTRACTORS DECLARATION � �'-. � �----- -"-"'- �"-� '-"-"-� "7 ' � "' "'- �"' � '___ _ _. _. _ '___ '.'_. "_"'_ '__ "UC. - QA55 NO. /7U. DWEl6 UNITS � / � t hereby offirm thot I om licensed under provisions of Chapter 9 nooRess 3151 Ai rwa �Ave. N No.409610 - � (commencing wilh Section 7000)of Divizion 3 of the Business and ,_, ; SEWER MAP : � � . � � ' - 409610' ,-•: � - - _. _ .___._ _ _._uc. , orte and eFfect. c�iv CO td hiesa C{� CLA55 �8----'- , -- �-----.. . . ..... . __.. ; .. TION .ProFessions Code,ond m I'cense is in fu�l f �"VAIIDA . . -... � . . BK. PG. � SQ.FT. NO.OF NO.OF._ ' CHECK ' � � , L tense Numbe'r� � �Lic.Class B $IZE -STORIES�� �� FAMILIE51 ONE �' . . . . . , . ,� _ M.. J VALUAT�N (�..� � � :�O 8 O.Q�A . _ U/ �_._ , � . .. .. .... . .. ✓_"_ ' N�-- � _ ... ConhoclorBramelea Ca�lf�. Dare - � � oexeiat NOF RK � � - � --� fir , -�- �, . � ADD � S CJ(O/ . �$• s C� -I ❑I om e:empt under 5ec. - -$111 �B_Fdfill� -_R2S1d2t1C2_... _ __ . ' .. . .... ALTER � � I •P.S�L O v B.&P.C.for this reason .� . �.� : . ' REPAIR.Q . S.... ..�...' :-- -- - ...... _ .. _ ' ' .,-- "' . .._._. .. ._ . .. '_'. .•. USEOF . . * _-_. . Dote: ... � . - . - . �/�/,-����� _- EXIS7ING BtDG. r10/�Q D�IX ❑ � � • °��+2��J lJ� ' •__ $ignaiufe ' �'''WV'�!/ ._........ APPlIG4NT TEL. .`..�._ ..�...'_'_' . .�. .. .... �i PRwn Bruce L. Abbe No.850-1001 `;L, ; ' OWNER-BUILDER DECLARATION �-�DA E`- ��.a• + , ,._ &1 9-&6 � __.._ ---. _ _. .._.._.._..... .__ _ ..'--'_--..0. .__..__._. ....._:,.� -IherebyaffirmthallamexempHromtheControcror'slicensa qDDRES531�J1 A1PWa Ave. N Costa M05d � � Law for 1he following�reasan�(Sectian 7031.5,Buslness ond . �RNAL ' '�� - -' "' �' � ' � � � � i . B _ .. _..,.. �Professlons Code• " � g�qoiNG ' �� y __ � � .. .__..._._.._._.._. ._ _.. .__' PRE NT __ _ _._ . .... . . � I, as owner of the properfy, or my employees wilh ADDRE55 . �O 8 O`J A , . wages as�heir soln compensotion,wi(i do tne work ond ' �-- - � � � � the sirotlure is not iniended or oifered for sale(Set�ion ����TY � - � • • ••� � � � ---7044,Bvsiness and Professions Code): -. -. ... .-"'� MOVING -�--.- .-... . .. -....... ..-. . TEL.. .._._ ...-- , ,�-�- � ----- - '-�- . � - . i � 1,as owner of fhe property,am exclusively tonlroding CONTRACTOR No. , � � °-�-�� �- _ r��•�4 8 G.�5 Q �. ' �with licensed coniractors fo constrod the project($eP ......' . -_._..__ ... _.. ... ....._.._._......._._.._____ _ . ..__.. __....._. _..__' ".".: �'._ _ __ . ..._ � �.,.: ' .'.. .. ..... . ; lion 70A4,Business ond Pro(essions Code). A�DRESS , � °."(L s�.Jr Q T � � ,� � . _ ..!� c .REpUIRED.._ __.iOIALSEIBACK M.. XI T. �'- � �� � �� � -���-'" - "-� CONSTRUCTIONLENDINGAGENCY"����""'" "--'-- " YARD� �HWY � � SET BACK PROP.LINE WIDTH ....- �-- - -��----- ..- .. .....,....�. ._.._.. ._ ...: I hereby a(Firm that fhera is a conslrocfion lending ogency for FRONi . ,i ���1;9�&.6;. � the performance of�he work for which�this permit is issued '--'--- -P.L---.._ __-.-- _-._- --'. ._._ ..... .._...._. ._---; __. .._---.... ��.,;'- . .�.-.- -_.. ... .. . _ . (Sec.3097.Civ.C.�. SIDE �� '� . ,� _'_ ___ . .._.. . . ._ _.. �... P.L .. _..."__'."' . .,,, . ,` : '. `� .>.: . : - . . . .. . . ....__......._._._ .. . . � .__ ..� . __ . . ...._ _,, -Lender's Name Toronto Domi m on Bank- -TT7�T p // IDMA ReL F ..�.�, . . .-.' . .._,r� .-- _ .- ��4. dnsomg St. U�te /UU ,._.,.. p,G Fee E �--�0�•Q - Permit Fea '7"-� '� � Lender's Address�an:• .,�tI - q � � " � ' � "�-- ..I[eriify Ihot I have read thia application and sto�e�ha���he _ _._._ o�d"�ItI._.__/SS�._. Issuon<e Fee- ---/d'SU�-�� LDMA P/C M '- �� � _ -__ _. above information is torrect I agree�o comply with all Counry imesr�a�ion Fee � �p � � � � __ordinonces and$�ale lows rela�ing to boilding constrvction, 9 � � � i,,. . . '_.'_.. ._'___._._....'_.._. _._..... ToialFee .'. ' "..-.... ' _IDMAPerm.M.-'...'_. "'. ..___ :.____._. _.'. ..' _.f and here6y authorize represeMatives of ihis County lo enfer - , opon Iha abava-mentioned prop rt for inspeclion purposes. . • , _ _ _ .___ _... .._. _ � !"_"_ _.______.. .._._. - ':- �._'__- _ -. ....._��... ��'6� _ SEE REVERSE FOR E7(PUNATORY UNG� , . . �. ' � . -_. -._ SignaWreof ApplimntorAgent. . .Dare.. .... ..........._ _.'_ _. .__'_..____.'...' "____..__.....-._..__'.__'_'_.'__�_"'_' _ _ . :,._ ,... _. ___.:l.._ .� ...__. . .:Q.i f . -' .. . _ � '.O _" � �.... ..,. ; '� ...-.-_ -p_ .-�i1' -Gl•. .�' � �4 I N .T� t� O �.W N O �' . . r. nV � C. O O. �O S . �. ..� r O �� n'w O' � �9 p I(�D � :: N "�'' f J�O � � c� Q ��^ �. � � 9 r. 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