HomeMy WebLinkAbout0886A 0887A I Y . � ..._ ..._. .. . .. . . __ _ . _ . .. _ .
� . WORKERS'COMPENSATION DEPLARATION � . ._.. . . .... ...... . . ._ _..._.. .._._ ___ ..... .- '.'' - . ..
APPLICATION=_FOR,BUILDING PERMIT � �
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�I here6 affi�m iha�I have a certifico�e of consen�to seli '
insure,or a cerlifitate of Workeri Com ensalion Ins�ronce,
o�'a ce�+iRed copy thereof(Sec.3800,lob.C.) ' COUNTY OF LOS ANGELES . BUILDING AND SAFETY �
��YNo61WETX7993comPo�yHa'rtford Group _.,. � -- - ,
BUILDING
Certified copy is hereby iurnished. FOR APPLICANT TO FI�L IN ADDRESS 2����- �'. �
� � Certified copy is filed with the cou uii ng inspe- " � BUiLDwG �,
ro de a�r e . ' � � � nooQess 24442 East Thunder Trail �
,/ _. ... _. _. --._ . _ .-
Dafee��PPlimnt � ! CIiY ' ZIP IOCAtIN . _. .
'' ' �'CERiIFICA7E OF EXEMPTION FROM WORKERS' -NO.OF BlDGS:� - --�- NFAREST.._.... ,
, --�-- -- .. . _ . _. _
��� � � �� COMPENSATION INSURANCE � � - SRE OF LOT NOw ON tOT CROSS ST.. ' '
(TMs section need not 6e mmpleied if tha permit�is(or one - � / ��� a.55E550R . -- � � � ' � '�
.hundred dollars $100 or less. . TRACT \/ BLOCK l0T NO. 3���'� � MAP BOOK- PAGE PARCEI �
( ) � 7EL. yyy5557� 7
I tertif thal in the erfo�monca o(the work for which this OWNER m �111' d -- � No. 5 -�1001 �{�73 A �P /���^J } I
..- �r��/�J� SFECIAL .. _.._ 6
permi��s iss�ed,I shall not employ any person in any manner pDDaE55 -- - ' '
so os to betome sobject to the Workers'Compensat�on tows. "Ldd 0 CONDITIONS 'O
_ _ -_. or� Costa Mesa _CA_ -_-z�P 92626._ - � I
Date�� APPlicont � ARCHITECTOR ' TEt.
� '$ICE TO APPLICANT: If, oiler makin� Ihis CeNificata of . � DISTRICT GrtOUP TVPE_,. _ .FIRE.._ PROCESSED BV . �!-
�npiion, yov shoold be[ome subject to th0 WO�kers' ENGiNEER Na� - CO�S�^ Z�NE U
Compensafion provisions of the Labor Code,yo�must forth- ADDRE55 3990 Westerly P1.� SU1 t2 ��� . .- .�v_. �3 j�I W
_ . i! a
wi�h comply with such provisions or this permit sha�l 6e ���� TEL. STATISTIG�MSSi�ICATION ' / APT. CONDO. �
deemed revoked. � .. � �� .�. �. COMRaCTOR Cal' No.850-1001 ____ . �Jv - _-_-- z
. __ _
LICENSED CONTRACTOR$�ECIARATION � � - � - � ------ �-- �-��� -� -UC.- �-- Cl/+SS NO. DVhtt.UNiTS�
I here6y ofiirm�hat I am litensed under provisions of Chopter 9 nDDRESS NO. ,
(commencing with Section 7000)of Divisio�3 of 1he Business and • IIC. - -... . SEWER MAP � '
Professions Code,and my license is in iull force ond effect. CITY COSta M2Sd CA QA55 B - BK � " "' " � -' 'VAUDAT�ON (�
� �-� ' ' , $Q.FT: NO.OF NO.OF . CHECK • ::V U t1 U�7 "
Licensa Number 409610 � i;�,cia„ B � SIZE - STORIES � - FAMItIES .� ONE�� � '� ��� ; ,
. .. ,, . _VALUATION. , .... . .__._._ �:• • o •2 .
Bramalea Calif. oES�R�PTo� woRK PLAN 24. "E"'
Convoc�or Date ADD g S I/ �� , - G •j ll,�i G� �
�I am ezempl�nder Sec. ALTER ❑ . �
8.8P.C.for this reoso ❑ s - - ... .. • n�!! yl.��?-,
REPAIR
a��e: usE oF None oenno� ❑ 0 F 2 0-�G
EXISTING BLDG.
. .�$i nOfUre � � APPLICANT TEL ' .
9 PRIM George Vedel l Np HSO��OO ' FINAL
O N R-BUIlO 0 ARATION DATE�-�/�-�'� - --•-
v a � 3151 Airway Ave.,N, Costa Mesa
I hereb affirm ihal I am axem t from the Conimc�or's License ,yooae55 FINAL - � - '�'�
Law for�he(ollowing reason(Section 7031.5,Business end _
�-�Pro(essions Code): � - " �' -� vRE EN --By �C�������A
� BUIIDING . . �
I, as owner of Ihe property, or my employees with AD�RESS l: • • ° . •-�.
woges os their sole campensaiion,viill do the work and '
tha struUure is not intended or offered for sole(Section ����TY , . , � o J f�[i� _.
� i o�e 7044 56ui�es so d P�fen eodcCode).Praject(Se c .. _ D Q�DOR ...._"� ..-�. . lOint 5eienCo . .. . ._..� ..-•.,. . ��� '._. -- � C S�G o.s V�J �
YARD HWY .. _ . . . - ..__. ... _ ..,
� -"CONSTRUCTION LENDING AGENCY Sei BnCK PRpP,LINE WIDTH . '
I hereby atfirm ihot thera is a tonstruction lending agency ior cRONT � � �� . •
the performente of tha work for which this permit is issued � - -a.l. - -- - - ' ' �-" - - ' - - - '-
(Sec.3097,Civ.C.). SIDE , . � . .
m Toronto Dominion Bank -- P��� - - �- - - ,
I m Lender's Name • lpN,q Re1.M , ' � �
•� P.�.F«s ��3•6 z., �.m;,F�, - � 7•sn �
- lender's Address$a�Eranci sco f.A 9a1f14
I � .I certiiy Ihat I hava read ihis apPlication and state ihat the ._ .. . . .�S_�� ..- issuance Fee - �.�D-..�. ��nnn P/C N -- . . ,i `.- - �-- .. .' � ' .
� obova in�ormorion Is cvrrect.I agree ro comply wilh all County invesrigonan Fea
g ordinances and S�a�e laws reloting to huilding conshuUion, ._ ._ .__.. __-. - io�al Fee � ��v -- � -IDMA Perm:M -- � - �-� ��--.-� '
u and hereby avthorize represent tives o this ovnty to enter � , _ -_.. "' �
m opon the a ve-men' d �o erty fo in lion pur osv�q ._ _. _.. __ �� __ _ _. . _ ._. _. . . _I --- ..._..-__ ..
/11 �ti�l� " - - -- �.�
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a ��VI/ SEE REVERSE FOR EXPIANATORY IANGUAGE . � � ��� y � _
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