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HomeMy WebLinkAbout0673A 0674A (4) WORKERS'COMPENSATION DECLARATION � I hereby affirm that I have a cerlificate of consenl to self APPLICATION FOR BUILDING PERMIT fnsure;or a certificate of Workers'Compensatfon Insuronce, � or a certified copy thereo((Sec.s800,Lob.C.) CpUNTY Of LOS ANGELES BUIL�ING AND SAFETY PolicyNo.�����pan��g � � ' � CertiFied copy is hereby fvrnished. �� FOR APPLICANT TO FILL IN nooaess ��O G+4.s.r�' �C• �� Certified copy is filed wirh ihe covnty building inspec- BUttDiNG t r ndepartmenl. ADDRE5513O� S. Longview Drive i�,�iTM 1�.,�� NEAREST Dore nppltcam an Diamond Bar CA zia caosssr. ERTI ICATE OF EXEMPTION FROM WORKERS' NO.OF BLDCS. assESSOR � COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL ' (This section need not 6e compleled if the permil is for one 7RAtt 42558 52 u5e ZONE MAP h�ndred dollars(5�00)or less.) BLO[K LOT NO. /��r! NO. � �I� � . TFL �� �'� $PECIAL y � I certify that in�he performance of tha work for which this OWNER � � NO. — /�'�� GONDiTiONS � d permit I5 issued,I shall not employ any person In ony manne� �151 Ai rwa Avenue Sui te N DISTRICT GROUP tYPE FIRE PROCESSED BY � ._ so as ro becoma subjecl to the Workers'Compensation laws. � /+DDRES y � �O �� CON ZONE V �,TM Costa Mesa, CA z�P 92626 0 Dote Appli[anf . STATISTICALClP.551FICATION APT. CONDO. V � ^'pTICE TO APPLICANT: If, afrer mokin9 this Certificafe of ARCHITEROr� tet. .�--� lemplion, you should become subjacl lo the Workers' ENGiNFFR H ffl B 552 1 II NO. 2-1 C1A55 NO. '� DWELL.UNITS=f_ � -Compensolion provisions of the Labor Code,Ya�m„5�ro,rn- . A�REu 3990 Westerly Pl ace, SU1 t@ iJO . SEWER MAP � wllh comply wilh such provisions or this permit shall be TE� z deamedravoked. . , GONTRACTOR Bramalea C.a��f. N0.S50-1��1 BK PG, VALIDATION - LICENSEDCONTRACTORSDECIARATION � 3151 A71"Wa,y� $t.N ���•409610 1 hereby affirm Ihat I am licensed under provisions of Chapter 9 ADDRE55 MO. VAlUAT10N � � � (commenting wi�h 5ection 7000)of Division 3 of the Business and CO Std Me sa CA ���' Professions Code,and my license is in full forca and effect. CiTr � G1q55 S ��I �U JJ , SQ.FT. NO OF NO.OF CMECK �0 6 Z 3 A Licensa Number 409610 - �;�,eia:s B SIZE 1884 STORiES 2 FAMIllES 1 ONE Comroc�o. Bramalea. Calif,na,e G—rJ—H�J DESCRIPiIONOFWORK N� � s �• • • ;2� " ❑I om ezempt under Sec. 51119�2 Fami 1y Resi dence A�� � I •J 2 Q�L� . AITER � FINAL B.BP.C.for this reason NE'W Constructi on REPAiR � DATE � p/�(y • •3 2 Q 4 1 u � USE OF FINAL Date: EXISTING BIDG. ��`�� ❑ Br �� 0 b 1 3-8 5 � ��Signature AP�pRjMT BT'UCe L. Abbey No',850-1001 . OWNER•BUIIDER DECLARATION � I hereby a(firm Ihot�am exempt from tha Comr cte' se A�oREu 3151 A71'wd N. COStd Mesa low for tha followtng reason(Section 70.31. Bu ss and y+ 1�6 7�4� Professlons Code): � . paE " � - . BUIIDING •� 0 I, a�awner ot the property, or my employeee wiih qDORE55 � 4 �Q - wages as their eole compensation,will do the work and ��L'n,� � . the sfrucwre is not tmended or offered for wle(Section - � . 7044,Businesz and Professions Code). . MOVING 7E1. . � . � I,os owner of the ro erl om axclvstvel controctin CONTRAROR tuo. � �' � � � � � � , P P Y� Y 9 •549,OOc=i with licensed conlrocton to construd the project(Seo- qDDRE55 ' tion 7044;Bosiness and Profassions Code). . ' . - 0 Q�3�$5 REqUIRED TOTAL SETBAIX fROM EX�ST. - � - CONSTRUCTION IENDING AGENCY SET B/+CK YARD FfiVY PROP.LINE WiDTH , � . � I hereby affirm thot lhere Is a cons7ruction lending agency for -FRONT � �� - � � - tha performance of the work for which this permit is issued v.t. . ZSec.3097,Civ,C.). SIDE - ' • ' �� � P.L. Lender'sName Toronto �ominion Bank } [' /�-� • 114 Sansome St1'. �Il�te �Q� p,C.Fea S �3 L�• � Permit Fee v.J-O'�V � • lender's Address � I cerlify Ihal i hova read this appl(cation and state that�he � Issuonce Fee ��'� � above informolion is conect.I agree to compiy with all Covnty invesngm�on Fee �+`/Q - . -ordinances and State laws relating to bullding construUion, Total Fee v? 1/�� � bnd here6y au�horfze represeMatives of this Couny to enter - . � upon tha abova-mentioned property for Inspectfon pwposes. - M� �O� p'���f� l� Oa , . SFE REVERSE fOR EXPLANATOIIY L NGUAGE � � Signarure of Applicanf or Aqem pate � . . . . ..�t a Z o a` . ' � 2_ a.1\-_�% ' ' '',;. \ � G� ` p p �" �t 1` ��'� \' s .. N O p.. � 6° � �O R � M _ �� '�c��O \� .q � Q m n N t(C.�, t0 O "T� %• 'l� �C� ir. �' ^° .o °''' � "k- � n - ,` \�` ,5 r. r 7 p � � n9 '�. i '�. N'. � �� � � rl. r u+ o m O � G ca'fl `, o o ��� � �5.• � �l'1� 1� `'t � o, c � 'RY ._, ucp p�i+ 'D n \. .- �� r 3 Q 6 d O O tt . � "c n. '` f �i . 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