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HomeMy WebLinkAbout1089A 1090A (5) WORKERS'COMPENSATION DECLARATION � I hereby affirm that I have a certiFicare of consent�o self qPPLICATION FOR BUILDING PERMIT '� ins�re,or a certificofe of Workers'Compensation Insurance, or a certified copy thereof(Sec.3800,La6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyN�1T+IBRK�F�FH�+Company HARTT'ORn C; ni1P � Certified mpy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 � 'U d..jk-���.r - T . � Certified copy is filed with ihe co�nty boilding inspeo BUILDING p F1 tion deparfinent ADDRE55 LOCALITY .�J �� NEARE57 oare qppiicanr w �� cirv DIAMOND BAR ziP czoss sr. CERT ICATE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT — MAP BOOK PAGE PARCEL (This section need not be completed if ihe permit is for one USE QN MAP hundred doilars($100)or(e55.) TRACT BIOIX LOT NO. I�F �7�� NO. TEL � SPEQAL A I certify that in the performance of the work for which this �WNE�R��'�I''� T'IMI�ED NO. — 001 ��� CONDITIONS �- DISTRICT GROUP TYPE FIRE PROCESSED BV �� permit is issued,I shall not employ any person in any manner CO Z E �) so as to become subject to the Workers'Compensation Laws. aooRess 3151 AIRWAY AVE. SUITE N e lo �-3 cirv COSTA MESA, CA, ziP 92626 ' �� ."�' Date Applicanl STATISTKAL CLASSIFlCATION APT. CONDO. NOTICE TO APPLICANT: If, after makin ihis Certificate of F�RCHITECiOR TE. /��y) �+ _ 9 ENGINEER ARAM BASSENIAN No. -1864 CLASS NO. "%" OWELL.UNITS� ^'� �nption, you shouid become subject to the Workers' � �ipensation provisions of ihe Labor Code,you must 4orfh- �qDDRE55 3990 WESTERLY PL. �k170 NEWPORT B . �WER MAP �! wdh mmply with such provisions or this permit shall be �: deemed reVokefJ. CONTRACTOk BRAI`'IALEA CALIF. Np_ -LOO1 BK. PG, VALIDATION IICENSED CONTRACTORS DECLARATION S�E. LIC. I here6y affirm tha�I om licensed under provisions of Chapler 9 ADDRESS No.409610 yq�UAT10N (tommencing wifh Sedion 7000)of Divitian 3 of the Business and LIC. Professions Code,and my license is in foll force and effect. CITY . CLA55 5 `-�� �� ► - ' so.�r. No.oF No.oF cr+ecK ' � C�'�'�' License Number 409h1 D Lic.Class R s¢e 2542 STORIES 2 FAMIUES 1 ONE i � I g t?° «2 1 Confractor Ab AT. .A A.T . Date � DESCRIPTION OF WORK NEW � ' • 5� i ,� G ADD ❑�am exempt under Sec. SINGLE FEIMILY RESID�NCE A�TEH � FINAL + ���i: " i u:`� 8.8P.C.for this reason NEW CONSTRUCTION � DATE �'////�(�. REPAIR Date: uSE OF FINAL �1.U�--'E 5 , EXISTING BLOG. NONE DF.MOL ❑ By P . Signature APPLICANT TEL �'�'���''� OWNER-BUILDER DECLARATION PRIN7) $$Y NO. SO— OOI I hereby affirm that I am exempt from the Conirac ' nse , qDDRe55 3151 AIRWAY AVE. N. C.QSTL� ��,' . ► ���� ��S C�� Law for the following reason(Section 7031.5, iness and ' ' Professio�s Code)� PRESENT ��° � � ° ° � � BUILDING I, as owner ot ihe property, or my employees with ADDRESS j ��`.'� � �� wages as their sole compensalion,will do the work and LOCAUTY the structure is not intended or offered for sale(Section d „�_�: •;.,r�;� � 7044,Business and Prafessions Code). h�ovWG TE�. ' � CONTRACTOR NO. I,as owner of ihe property,am exclusively controcting �i'].(^,'2—�v - wifh licensed mntractors fo construd fhe project(Sec- qDDRESS tion 7044,Business and Professions Code). REQUIRED YARD HWV TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY sei BACK PROP.lWf WIDTH ► I hereby affirm ihat there is a construction lending agency for FKONi the performance of ihe work for which this permit is issued P.L. �Sec.3097,Civ.C.). SIOE P.�. �` Lender's Name TORONTO DOMINION BANIL / � 114 SANSOME ST. SUITE 700 P.e.Fee g ���,. �� Permit Fee �c? 0� - Lender's Address S[�P� $$d1AT6=669� 6�—i�•�^o�' � f� `.S� I cartify ihat I have read this application and stale Ihat ihe issu ce Fee a above info�mation is correct I agree to mmply with all County Invesrigaiion fee an P ) g ordinances and S�a�e laws relating to building construction, Total Pee Ct%'S~/• � � and hereby authorize representatives of ihis County ta enter � upon ihe ahove-mentioned property for inspectio purp ses. y/�� e�g. —p��,� �� � v,' `� ^ � SEE REVERSE FOR EXPLANATORY LANGUAGE Signa�ure of Applican�or Age pa� �s _ ____ ._._.._.._ -: ------ --�- - --a--------- �- --.__ ._.___.__._}.-- - - -- � � > > a c c c '-" o � a ° ;�°;� ° � ° i nv �ti i � � -n � � � i c� a ��� t� � N i _T� ,� � � � � �c'� ^ � R- I o � � � �p � o � y m !Yo � � � � � o i � � m � � � ,� � �no� � ' � G � � � = � � 7 � � s � �---- i I� �'z x c�� f -.. ,r� � �a � ,� � ' -� 1 �. �� a o ; n I I '_ ��� � s�� N � lk� l � � n 3 n, � � � Q i m I '� � N� , c � � i � � i oo ° v � 4 ! � � "� I � i �� �" o o f � a m W ° ". � ' ° � � � � ^ � � I ic � � � � � � 2 � � Jo � c� ! �. � D i � f � i ' � � � � �� --o' ( 4 I � f � e � ( i . _ � —�_._..�_.__. � ! �° � .� �i! -.�`;� `_.�—. 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