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HomeMy WebLinkAbout1109A 1110A (5) I � WORKERS'COMPENSATION DECLARATION �9 I hereby affirm that I have a cer�ifimte of mnsent ro self qpp��CATION FOR BUILDING PERMIT � insure,or a certificate of Workers'Compensation Insurance, or a cernfied copy ihereot(Sec.3600,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No61 WRRKG4RLCompany j�],�jZ'jF'(1RT1 ('_RlIiTP � Certified copy is he�eby tumished. FOR APPLICANT TO FILL IN ewto�NG I ADDRESS J J�-' 2 • � Certified mpy is filed with Ihe county building inspeo BUILDING � tion dep rimenf. ADDRE55 1419 S. VEILEVIEW DR. ioccuTv oare(��nppiicanr arr DIAMOND BAR ZIP _ CROssSST. CERT FICATE OF EXEMPTION FROM WORKERS' NO.OF BL�GS. ASSESSOR COMPENSA710N INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL � (This section need no�be compleied if ihe permit is for one USE ZONE MAP hundred dollors($100)or less.) TRACT 42556 BLOCK ior o. 16 No. TEL SPECIAL � I certily fhaf in ihe per4ormance of 1he work for which ihis OWNER rj NO _ CONDITIONS Q. permif is issued,I shall not employ ony person in any manner 3151 AIRWAY AVE. $jTITE jQ DISTRICT GROUP TYPE FIRE PROCESSE�BY �i' so as to 6ecome subject to the Workers'Compensation Laws. nooee55 � CONST/ iJ C' ,�.: arr COSTA M�SA CA. ziP 92626 � �� �7 Date ApplicaM STATISTICAlClASSIFICATiON APT. CONDO. ARCHITECT OR TE NOTICE TO APPLICANT: If, after making ihis Certifimte of �..a �mplion, you should become subjad to fhe Workars' ENGWEER r, . - 864 CLASSNO. � OWELLUNITS_ � Li. pensation provisions of Ihe labor Code,you must forth- u't wifh comply with such provisions ar fhis permii shall be AD�RESS 3 0 WE TER Y � SEWER MAP � deemed revoked. TE�� BK. p6, VALIDATION co��TRncroeBRAMAI.EA CALIF. No. LICENSED[ONTRACTORS DECLARATION 3151 AIRWAY AVE.� I hereby affirm ihat I om licensed under provisions of Chap�er 9 ADDRESS ' No409610 yq�UAT10N (commencing with Section 7000)of Division 3 of the Business and � ��� Professions Code,and my license is in full force and affect. citvCOSTA NIESA CA. 92626 CtA55 $ 3 �}j{P Q , �:�� -+ ��(�� 409610 B SOEFT NO.OF NO.OF CHECK License Number Lic.Class 163 STORIES 2 FAMILIES L ONE +}.• m a e C'I BRAMALEA CALIF. ���_f p��-- NEw � $ Confracfor pofe _ DESCRIPTION OF WORK I •G�+L�Q il ��.����..� ADD ❑�am exempt under Sec SINGLE FANILY RESID�NCE AiTER O FINAL � �%'i'.%C c%� B.&P.C.forthisreason NEW CONSTRUCTION REPAIR � DATE 7/ � . use oF G l,�c—E?:. DOfe exisnNc aioc. NONE DEMOL ❑ FINAL ey Signafure -- APPLIG4NT TEL. OWNER-BUILDER DECLARATION PRWi) NO. —IOOL I hereby aNirm thal I am exempt from the Coniractor' 2 •, < �j � 7 (,f'l Law for the following reason($ection 7031.5,Business an ADDRESS Professions Code): PRESENT �:� " � ° d m 1 � BUILDING I, as owner of the proprny, or my employees wi�h Aooae55 ( �4��4 v(; wages as iheir sole compensation,will do ihe work and �Q�A��TY � - the structure is not intended or offered for sale�Section ,� �,l+£._� r,`�T 7044,Business and Professions Code). MOVING 7EL. u I,as owner of the property,om exclusively contracting CONiRACTOR NO. 4� �. 7,C2`8�. wilh licensed confracfors fo consfrvct ihe projact(Seo- qDDRESS tion 7044,Business and Professions Code). RE�UIRED TOTAL SETeACK FROM E%IST. CONSTRUCTION LENDING AGENCY SET BACK YAR� HWV pROP.LINE WIDTH ► I here6y affirm ihat ihere is a mnsiruction lending agency for FRONT the performance of ihe work for which this permit is issued P.L. (Sec.3097,Civ.C.). SIDE Lender's Name TORONTO DOMINION BANK P� S 114 SANSOPIE ST. SUITE 700 p 7i�,d'f) = lender's Address SblN FRl1DTCISC9� Cl�. Q�1 fl� P.C.Fee$ �d�rQ3 Permit Fee � I certify Ihat I have read Ihis application and state thal Ihe Issu ce Fee �^v� � above informotion is mrrect.I agree to comply with all Couniy Investigatian Fea �n � ` \ g ordinances and Stale laws reloling to building consiruttian, Toml Fea `1�� and hereby a�thorize representatives of ihis County to enter m upon the above-mentioned property for inspection purposes. 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