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. "Mlt,.,�. /d G ���
a �, �, ���� � 1
SEEREVERSEFOREXPIANATORY LANGUAGE
Signature of Applicanl or A9ent 0�e �s
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