HomeMy WebLinkAbout1099A 1100A (5) 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� �:
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