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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� �: .._._ ____..___�___.._..._ _ ...-- ' r"^�C)2� - � r m �.; � N T....N r�.., _ '_' __'_'�..._..c"_'_��.._.._�,v ._.'_�.-�^ -T -_.._� _..... - ._�����-� 3 3�i Q � Q 4 e Q�C � O�� � � Q� i m � (p i G � C p.^� � v� W O ��.'V' � O 7 n � N � '(_ — I c s 's� 3 � �-, "' � t7 � � � � _ Q m i �� __�In R' m �G! � ro C Q O t ."sy' � t Q � N _ �j � lC i S � � E� � I--7_� x �� ': - " �-� I -3 f 3 "- J�� � c i � n � i . 1 i-•, ��cl � o £ � � o � � ( � � � 9� p= ❑ -� � � �� ,� I! � � � O 6' O y � ' � { ' � I � N � O � � I Q n t e� I � N � � � � p i f � �' � (; y i � ' c2 G `�" � � �~ �I i � `= n ( �` ° � c � � � Q I I � �.� � � � � ! �� � I �. �j i � �__..�.._.�_l_� J�- -- -- � � ' I � ��� � ��� �, "-��� g � � � � i ;����� � � - �-- ._ ._ ---- �— �-- -•-- —�" �� �, i`�� '�— � r� • ! ,�� w � �� I�--�� `� ! � �e ': u p �,_�_ _ s+_ , 'v �`�� `�� � ' I i �w � � m -�=--�— --�-.--I�-- ---f--- .� -� \ ! �-- , _ _� � - I � ��a 4� � e� I P � ! 1 1 a c,o � � � I � �n. � � 3 P3 I A I � I� � I�. � � I _ . 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