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!
-.�`;� `_.�—. L� f'_..._.._,.i O_ � I i I �
�. i\I�.\i�E c y� f ,7 � I �'a �! A
m
e N
� � °C '�--j• I — --- — -- - ---�- — �
--a_�, ��.1��� �''� ° � ���� � � "�
v� `� , �v� _ .�.J..._._ !��' .�� ! � �
�� � — -- — --� ' � � �
� j '� � �i II . ' � � � � � ; A
� � j� � ' � � � _� ° .I �� �. �
i I � I �, �.. � �� � ;�. � � � � s
� ; � i -- I o �
i � � � 'a I ^' , 'o� ! �
I . � � � � � �
� C � _ C � � �
� � � � '� a� s
� � � p' s�a.
--�- ---� - . ___� l_ -l--.. --- - - - - �.--�_ -
.., _�_�___ � , �
� i � �.
� � - . _ ..
, .� I � � �__ . :
_ , . .� : ► ��.
� � �
i �_: � { �
I.
� , � . , . i ,, - ; � - . �
� � ; �, : � p
I � .
; ; � � : � . . � � : �
i � - � f ; � , �
� �� � • � i � m�
� � I I �_ i -� � � : � "t�
I I � � � , � - : : : � , _ � �,
� , , ( � _
� I � , � � � ,
� � � il � - �
I � . I
I � � , I , � I , I � 1 ! ! ! i ; �
- � � I o m L%b ��o �' ��� o� �� A��� '' � x �n"'''� :a.� ��o � r-
{ - � cJ N � ��.ti N v� � 1 � �'a4 '� � ,,,��� °�r- s.y+cp : � ��c�j�V`, y:�.Y n �e0 ����� f�9 S
.. ... I _ : � — ^- � �� �-, � "' O � ��4 v o,�„ � N _ �e� 0.p O j.� � ? 4 �0 m m
1 a ro_ �Y�.af= _ ,a J ~Y (J �'� w " n `� - �r� `4 O+y 't� n �
I c I ,� � `t '�'' .A.::. i^� � O �� � H �� S � C Q "�,SA W V�� ,J,'„�.A Q._A �r`� w
, { I � , � y �� � � � o � v�e � o � �; o ��?.�. �o o � x n' � �,^� ^ �w lZ. F °::�
F �"y. a o b � o �.� . � f ��„'v �`'`h �-`'4 h ' J'
! x � `�� m � �, a- � �p
r .'ro �• � o � � a `.,��.c� � �e� m 3 x � .m ,�,�r, h y a 3 r,
1 ' � I E .,I. � P. n � LL(D 4i `S " � � C? O O cD � � 3 R =°�'Q
� _ � i � ; � .�^�, ,; a n o c�� o���`.� � ��c'`_ � a x "':���'y ,^�� '�� s x
; � I �A �j c . ,. a o c �� rs y�� �2., � n o `�''C k ' �� n ° ^ T� r
�sa� � ^. :� � 'C�. 3. Y m. � � � �•m o 3 � �m °_�y w� p n• m
_ I � :ii ..�' m � n -"i..�' ,� sa m �� :a'?,s � .,�', a 3 c� A� 'e s �,,�n 'r.�. H '"
� _.I �� �`-n �.'���� � �� v• �•a �S (�rt��'o `�- „N � � O A � �s y � C"'
I ,� � � n ' ca O m � y •��'� W a'., � p�
I � ;-., ,� �.�; a �..�:i 0.;� � �o o w o � ,� � �
I;rt'Y � 7,.'° 'I �W, J N r Q N n. Y Z7 f0'�„�.A� �`'� O �a «, � X w
� j . . «a .� � � � ° a'� � iy,'' �� o • m � �+ �; e� '' o` •� � m w
ti . ' I � �'�.� :n � .ti' .� N; "� o `? -: � � � � o y CC��„`�``s'o :.YF`..'n s2 3 �
" � a ti'° K c ro ° � ,n� ' �m � y a o � .�W�,- � s � C]
� ... . . I Q ^ ' �. , o a n"r. .
I : �� + � �x �` 3 e,�.. � „+�"'. ��a£ ���MA M.o o eo W�=�'� o � y
I. c..N n ...� K n. ra,• ��„•"n..� =3 a,A � y;,'� � � a '° ' o o ai
, �� F � ' a� „ � n c��i ; ^t Cw '.� � 0 0-'< q,"�' �'R.",,� `" :t'C`z � 3 r�,
.. I a J y��' � u .. � �y � l` � � ��h .���iZ ���•� :-�S �' y.
� � � � ^ ., si � a � ... � � �, x �
� N po ^ �'� < �; .:�,�,a �,'z n ,��'3c �a� �'iL.,•� p �, c::�y �,c� :,
� � �. , �° m s °�N � •� � � H � �'b� ° �'�`° m Cl :�?
n � ,`�� �.� '� � . � � �S'�.,`�� � �� o...p.�-v'M ° ��� A ;
_ ' � "j h. y � ^ j A u p �3 O N n Q � �O W '�, ' �a � � �
� � � `9 l.± A � C. � �, �' ,1, Jr H 3 A �"O� S,Q l��C ` p lp
� i � (� � i � y ... � �° �° ti �� :�w� ��� �2�- ~.^..`°`�x•`�'�x x �.`" o'o
`V�� 3 �C 6+�. �..� �
w�`C i� y �i