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
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