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HomeMy WebLinkAbout1103A 1104A I � WORKERS'COMPENSATION DECLARATION �+ I hereby affirm that I have a certificate of consent�o self APPLICATION FOR BUILDING PERMIT S insure,or a certificate of Workers'Compensation Insurance, or a rertiPied copy rhe�eof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY 61WBRIz4484 HARTFORD GROUP P❑olicyNo. Company BWIDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 U� �i���L't'a'��/- � Certified copy is filed with ihe counry building insper BUuoiNG Y /� ti n depariment. ADDRESS T LOCALITY �ate �Applicant��,,,�....-.tA. ['-'�^'',`-�y'-`-� CIT`!D �I ZIP CROSSST. ERTIF CATE OF EXEMPTION FROM WORKERS' ^1 NO.OF BLDGS. _ ASSESSDR COMPENSATION INSURANCE ��, SIZE Of LOT NOW ON LOT MAP e00K PAGE PARCEL (This section need not be compleled if Ihe peimit is for one 13 US�rQ�E MAP hundred dollars($100)or less.) TRACT BLOCK LOT NO. J�1') NO. TEl SPECIAL ?- OWNER ' NO. SS —LOO1 dG�� CONDITIONS � I certify fhat in ihe performance of ihe work for which this DISTRICT GROUP TYPE FiRE PROCESSED 6Y � permit is issued,I shall not employ any person in any manner 3151 AIRWAY AV�. SUITE N � a: so as to 6ecome subjecf to fhe Workers'Compensafion Laws. ADDRE55 CONST LO ��J h�-3 � a,Y coszA r�sa, c�. Z�P 926z6 � � Date Applicani STA715TICAL CI.ASSIFlCATION AP7. C NDO. f^ NOTICE TO APPLICANi: If, ofler mokin this Certifimte of ARCHITEC70R rE� �'5"� � g ENGINEER � j(� No. 5 -1864 C�A55 NO. �✓ - OWELL UNITS� "� �ption, you should become subject to ihe Workers' �„ ipensation provisions of ihe Labor Code,you mus�forth- qDDRe55 39gO WESTG'FLY PL. ��170 NEWPORT B 5ewek rnnP �� wifh comply with such provisians or this permit shall be � deemed revoked. coNrRACToa ERAi-111L�A CALIF. No.850-1001 BK. PG, VALIDATION UCENSED CONTRACTORS DECLARATION S E.uC. - - - I here6y affirm Ihof I pm licensed under pro�isions of Chopter 9 aooRess 3151 AIRWAY AVE. � ,vo.409610 VA�UAT��N `� � ' ('�"�� (commancing with Section 7000)of Division 3 of the eusiness and COSTEl i�'IF',SA CEf.. 92626 ���� B � n � H �•%� Professions Code,and my license is in full force and effecL CITY .+ CLA55 � r Q �p , � ��� Sq.FT. NO.OF ND.OF CHECK - LicenseNumber�nq�in Li[.Class R SIZE 1 $ STORIES 2, FAMILIES 1 ONE � D"C"�)G' ' Confractor RRAN�T.RA CAT.TF_ Dafa� DESCRIPTION OF WORK 23 BR NEVd � g ° `'`�=' ( �. ' � ❑I am exempf under Sec. �� SINCLE FAIIILY RL7SID�NCE A�� � O Z C�-'�F`,:' ARER � FINAL B.&P.C.for this reason NEW CONSTRUCTION REPniR � DATE ��� ( � USE OF Date: DEMOL FINAL `� E%ISTING BLDG. NONE gY Signatu�e�/...�n..-�- �• APPLICANT TEL. � � OWNER-BUILDER DECLARATION PRINT) BRUCE L. ABBEY Np. —IOOI. _� U A I hereby affirm thai I am exemptfrom the Cont�acror's cense qD�aeSs 3151 AIRWAY AVE. N. COSTA �S �C � ' Law for ihe following reason(Seclion 7031.5, Business and �'�g � � � ' � Professions Code): �i � ^ BUILDING � �'h'*r ��� � � I, ❑s owner of 1he properiy, or my employees wifh ADDRESS � wages as iheir sole wmpansation,will do fhe work and 3 ,, ;��(�.'-,`,� the structure is not intended or offered for sole(Section LOCALiTv r-,V 7044,8usiness ond Professions Code). MOVING TEL Q (,�i c—�j� IV I I,as owner of the property,am excl�sively coniracting CONTRACTOR NO. 4� wifh licensed contractors to construcf Ihe project(Sea qDDRESS tion 7044,Business and Protessions Code). CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETBACK FROM EXIST SET BACK �ARD HWY pROP.LINE WIDTH I here6y affirm that there is a construction lending agency for FRONi , ihe performance of ihe work for which ihis permit is issued P.L � ($ec.3D97,Civ.C.). SIDE Lender's Name ����}} c TORONTO DOMINION BANK P�� � Lender's Address �� ��I.�COT�CAUI�y41 V4o P�C.Fee$ ���i�� Permir Fee l:J��+�Q ' ��7.�`Z) I cerlify Ihat I have read ihis appiimtion and state ihat the Issuanre Pee ¢ above information is mrrect.I agree to comply with all County Investi tion Fee t�[ p � ordinances and State laws relating to building tonsiruction, 9� Totol Fee v/- /' v C and hereby authorize representatives of this Co�nry to eroer � upon the above-mentioned property for inspection purposes. �q�A� t,�� ��A(,+.,� ^ � fTC'l•/ T'VJ Z, SEE REVERSE FOR EXPLANATORY LANGUAGE Signowre of Applicant or A9ent Do� 8s � r°'!T�(�Z� l_ f!f �l U. T: �^T .� � J_� __._��� ( ^ T � �Y�� �d ��..__._�_ � I Q � � O �O � 4 � O_ (� n� � I ii: � -�- ' � � '� i � O O , 3 .�.� _.._._ � - _ _„__'_ Q O � �wo N � T � `� 3 3 � 3 �.Q n- i � � n � � o I Z � � ° � � f �• � O � ��� rn � O � 1 � a �n O . 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