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HomeMy WebLinkAbout1099A 1100A WORKERS'COMPENSATION DECIARATION �'1� I hereby affirm ihal I have a certifimte of mnsent fo self APPLICATiON FOR BUILDING PERMIT Z insure,or a certificate of Workers'Compensation Insuronce, or a certifieA mpy thereof(Sea 3800,Lab.C.) P�olicyNo.hlWItRK44Adgompa�y HARTFORD GROIIP COUNTY OF LOS ANGELES BUILDING AND SAPETY Cerufled copy�s here6y furnished. FOR APPLICANT TO FILL IN ao Ress f�'°z� ...�t".c.vt� � � Certified copy is filed with the coun�y building inspeo- gU1L�iNG �� �� n depa�tment. ADDRESS 1423 S. VEILEVIEW DR. LOCALITY �--� I NEAREST Date Applicont�TZ- �-.- '�^�.� CITV jQ $(� LP CRO55 ST. CER FICATE OF EXEMPTION FROM WORKERS' NO.OF elOGS, _ ASSESSOft COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT i`AP.P HOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAF hundred dollors�$loo)o�less.) TRAcr 4 (7 BLOCK ior No. 17 ��� No. I cerlify ihot in the performance of ihe work for which this OWNER$ � t-4ITED N�� �S�1001 ��� CONDITIONS � ermil Is issued,I shall nol em lo an erson In an manner DIS7RICT GROUP TYPE FIRE PROCESSED BV � P P Y Y P Y CONST,� ZO � so as to 6ecome subject to ihe Workers'Compensation Laws. ADDRE55 ],�1 AIPWAY AV�. SUI`rE N p �/ � ciTv cA. ziP 92626 r� 9` 3 '�`� � Dafe Applicant STATISTICP.I CLASSIFICATION APT. NDO. � ARCHITECT OR TE. NOTICE TO APPLICANT: If, after makin ihis Certifimte of (1'2) � ' .rop1ion, you should become subjed ta ihe Workers' ENGMEER [�.I'��'[ B N�� — CLA55 NO.�_DWELL UNITS� � �pensation provisions of fhe Labor Code,you must forth- qoDRe55 3990 WESTERLY PL. �r` 170 B CH. � SEWER MAP �'� w�th comply with such provisions or lhis permit shall be � deemedre�oked. coNrrtncroeBR[1ML1LL�'A CALIF, No. 714 BK PG, VALIDATION LICENSED CONTRACTORS DECIARATION LiC. I hereby affirm fhat I am licensed under provisions of Chapter 9 aooaess3151 ALRWAY AVE. j��' ,vo.409610 VAWATION (commencing with Section 7000)of Division 3 of ihe Business and ii�. _� C S'��/�� Professions Code,and my license is in full force and effect. CITYCOSTA MESA CA. 92626 CtA55 B $ QQ , S�.Fi. NO.OF NO.OF CHECK , ; °. m ��� License Number 409610 �;�,c�ass B �srze 1884 stoRies 2 Fnnnwes 1 ONE '� DESCRIPTION OF WpRK rvew s i �3 2 f.;[I 1 Contractor R A1�AI.+.A T.TF. Date nDD � '' '+ r c(,'.!i � ' ; � ❑�am exempt unde�Sec. SINGLE FAPfII.Y RESIDF.NCE A�TER � F�NA� t' B.&G.C.f o r t h i s r e a s o n N E W C O N S T R II C T I O N R E p q�R ❑ oare v�i �g� 0 7.0�_-8'� Dafe: USE OF DEMOL FINAL � � —^c1�� EXISTING BLOG. � B $ignafure ``'�,J — � P.PPLICANT TE � PRiNT BRUCE L. ABBEY No. 85 -1001 c. OWNER-BUILDER DECLARA710N � ( � ���n I here6y affirm thot 1 om exempt from ihe Controctor's C qDDRE5S31 S 1 AIRWAY AVE. N COSTA �' A�CA. �;e a o a a Law for ihe fallowing reason(Seciion 7031.5, Business and j Professions Code): P E ENT � BUILDING � �+�4 9.;�(�j I, as owner o4 the property, or my employees with A�DRE55 g wages as iheir sole compensation,will do ihe work and i z �' the struaore is not intended o�offered for sale(Sec�ion iOCAt�TY � °5<�l�i�'�c �T 7044,Business and Professions Code). MOVING TEL. i7�i I,as owner of the property,am exclusively contraCting CONTRACTOR NO. � l�U L'"'�i J Y'" wi�h licensed wniraciors to construd ihe project(Ser tion 7044,Business and Professions Code). ADDkess RE4l11RED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWV pROP.LIN WIDTH ► I hereby affirm that there is a consiruction lending agency for FRONT the perfarmance of the work for which lhis permi�is issued P.L. (Sec.3097,Civ.C.). SIOE P.L. Lander's Name TORONTO DOMINION BANK � 114 SANSOME ST. SUIT� p,C.Fee$ ��J•�J ve,m��Fee 5.;�-�--� - Lender'sAddres�AN FR._!�nT�'�.T_Sr� CA. 9�+LD�F ' � I cerrify ihat I have read this application and state that the Issuance Fee rV �� Q a6ove information is mrreU.I agree to comply with all Couny lnvesiigaiion Pee g ordinances and State laws relating to building construUion, Total Fee �-� and hereby authorize representatives of ihis Coonty to enter m upan fhe obove-mentioned property for inspecfio purposes. �p{,p a `� ' � g ���E REV RS�POR E7lPLANATORY t��UAGE �� n �ture of Applicon�or Agan� Do� �: .--- `� � � - ���o a __�..._..v ���' �� _�c._�-� ,, i �_..�...,_..�� =r:� co � C O 3' r� . �� ...- -- � m ° m � 'f�� �� c3, ?Q N`:�' `^�. :L1 K 1 � �..,. � :�is �� --'_"'.S ✓f -n N O � Q �' C` Q ' Q n � p .� vh �._..---�.._.r � � �c �a�� � `° � j �� 7 -o � 1 3 a e� � ` � -j ' � a�m � a o o � .� 1 � o'� o Q = � A � u� 1x ,�.-*1�C�x� r. 3 c � 7 � � � m � 1 ,. 3 ��eo �'s 1 u� ro . x ` �"� t °� ^. � r � � n_'" `^ � �.G� � o c p d � J� �, ' �3 O n� X �L; `^ N t� i , � � � � ��7� ��� � �� � �n tp 6 ^ 'l 9 '-' Q _� � ��+�'��lu p � � _ _ � � ��. tp -�i� O ' 7 � '< '.^J 1 � � � � cz1 i _ _ _ a �a _ - '� o j w � I ` — _, ' _ w �. � .� !9 „�-�, .�"� � - C 1 ` � p ¢ � � '` 1 �„._...--•�� �.`'�.1- "._, -�._^..� � S � t_.---'�" ��, �" ' O � �_._...�,--�-�� y �.� c � i � �-C., ��'. �., x. , ,,,._._ ' � � 1 -=1—.. 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