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HomeMy WebLinkAbout0653A 0654A (4) WORKERS'COMPENSATION DECLARATION �j I hereby affirm fhat I have a cerfifi[ate of consent to self : APPLICATION FOR BUILDING PERMIT 1S irSsure,or a certificale of Workers'Compensation Insuronce, �" or a certified copy ihereof(Sec.3600,Lab.C.) Poi��„rvo.61WBRK448�ompany_HdT"tfOPd GPOUD COUNTY OF LOS ANGELES BUILDING AND SAFETY � " BUILDING cerrified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 �- ■ �-�� ��, �rtl Cartified copy is filed with tha county building inspec- suuDING 1427 S. Stonecrest P,1 ace /� Ll,� fion depafimenf. AO�RESS - LOCALITY �/>'�° Date�_Applicant ....�.�. CiTV ZIP CROSSST. ERTI ICATE OF EXEMPTION FROM WORKERS'(� NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE J SIZE OF lOT NOW ON LOT MAP BOOK PAGE PARCEL (This seclion need not be completed if the permit is for one"� USE ZONE MAP hundred dollars($100)or ie5s.� TRACT 42556 BLOCK �oT No.35 �!�,� No. �'" 7EL SPECIAL Y 1 certify that in the performance of the work for which ihis �`�'�NER � NO. - �O� � CONDITIONS � permit is issued,I shall nof employ any person in an monner DISTRICT GROUP TYPE FIRE PROCESSED BY � r AooRE553151 Airway Ave, SUit2 N coNst. z � so as to bemme subject to ihe Workers'Compensation Laws. � c�T� Costa Mesa, CA z�P 92626 � �'� � f � Dofe Applicant STATISTICAI CLASSIFICATION APT. ONDO. M OTICE TO APPLICANi: If, affer making ihis Certificafe of ARCHITECT OR TEL. ENGINEER Aram Basseni NO. - G� � � CLASS NO. DWELL.UNITS � mption, you should becoma subject io the Workers' � -ompensation provisions of ihe Labor Code,you musi forth- qDDRE55 �.+,,�,,,,, SEWER MAP � with comply wtlh such provisions or ihis perrnit shall 6e - �-�-�-y---���-�'�'-r--��-1-t��'-�-+Z-��--- � deemed revoked. TE�' BK. PG, VALIDATION coNrRncroRBramalea Cdlif. . No. 850-1001 LICENSED CONTRACTORS DECLARATION �iC. �;i I hereb affirm ihat I am licensed under rovisions of Cha ter 9 ADDRE55 ND. `��r�"`�F� 1' P P VALUATION (commencing with Sedion 7000)of Divisioh 3 of Ihe Business ond (�,OStd Mesa CA 92626 ���' B n �'i o e o e('� Prafessions Code,and my license is in full forca and effact. arr . � c�n,SS T� /� 6 0 C� ► . 54.FT. NO.OF NO.OF CHECK � a��G S� �icense Number 409610 Lic.Class B SIZE 1430 STORIES 1 FAMILIES 1 ONE , Conimctor Bramal ea Cdl l f. Date 6/6/85 �ESCRIPTION OF WORK NEw � 3 0 2 5 2 L;8�; ❑I am exempt under Sec. StUCCO DW2��l Il J P�dtl noo � ��.� 3��� ALTER � FINAL B.&P.C.forthisreason Slll le Famil Residence � DATE J��d d's� REPAIR Dafe: USE OF DEMOL ❑ FINAL EXISTING BLDG.nnr]�,_ �_ e ,�,,� APPLp IRNT� Bruce L. Abbey No850-1001 $igmture • y ._Q�J j,.�,{�{ OWNER-BUILDER DECIARATION I hereby offirm ihat I am exempt fiom the Contmct4' ' qooRE55 3151 Ai rwa {�V8 N Costa Mesa � �� 6 6 � � 1 Law for the followin9 reason(Seciion 7D31.5, BJ" s and > > ProfeSsionS CcdO): PRESENT I =4.3�,7� � BUILDING � I, as owner of ihe proper�y, or my employees with ADDRE55 � n�; a,[\�C� , wages as Iheir sole compensafion,will do the work and - the sirocture is nm iNended ar offered for sale(Section �Ui,nui"r 7044,Business and Professions Code). MovING TEL. � C��� v'-�� � I,os awner of the properry,am ezclusively wntracting CONTRACTOR NO. ' � wifh licensed coniractors to consiroct the projecf(Ser qDDRESS ' � tion 7044,Business and Professions Code). � REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET eACK YARD HWY PROP.LWE WiOTH ► I hereby affirm ihat ihere is a construction lending agency for FRONT the performance of the work for which this permit is issued p.i. (Sec.3097,Civ.C.). 51oE Lender's Name �7 [ Toronto Dominion Bank P` 144 Sansome St� SU�te 7�� p,C.Fee$ eC��+O Permit Fee ..�. .V!,✓ Lender's Addressc������TSTg eB�n�(���n� I certify thot I have read this application and state ihat ihe Issuance Fee ��"Y� above informafion is mrrect.I agree la camply wiih oll Couniy Investigation Fee y'�7� r ^,,ar� ordinances and State laws relating fo building consfruction, Tmol Fee /��7` Cs°V � and hereby authorize representatives of this County to emer upon ihe above-menfioned properfy for inspection pur osea /g,�� !O�, ���� �� f! ��� � SEE REVERSE FOR E7(PLANATORY LANGUAGE Signature of Applicant or AgeM __ pot �s , �-'-- _—'+-n�o C�r �v 1 �i T..� �; J .. � ,`x 3 p �"tn =r r-'p`-eC`'—�^ T i T� - —=-�� .� e �y i7 3 n o a t g i � � � a i O �O n 4 i C1 6 f; � f c3 3 n � I s�� � S S 7 �. . Q � y i O (g � 6�"' i O � —_� �• i Q I a'2 �.�"'= l_..�� r' 3 !1 i; ` � j^ �� � � =' � �—I' �� � I � � . `=' �, � 9 � i p ! € il S�� �� �� { _ � � �t �:� 3 i � � , '.. 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