HomeMy WebLinkAbout1111A 1112A WORKERS'COMPENSATION DECLARATION ��
I hereby affirm �hai I have a certificate of consenf fo 5e�f APPLICATION FOR BUILDING PERMIT �
insare,or a cenificate of Workers'Compensation Insurance,
o�a certified copy ihereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNoFiIiSRRKlaGRGCompany�[Q$TFIIRTI GR(1TTP
Certified copy is hereby fumished. BUi�OWG ) z� ��� 9A
FOR APPLiCANT TO FILL IN A�DRE55 ! • <t-Y,-� *
� Cerlified copy is filed wifh the county building inspec- BUILOMG
�io�deparfmanf. ADDRE55 1427 S. VALEVIEW DR. iocnurv �,,v7+
Date(���Applicant, ._.`�, aTY DIAMOND BLiR zir cROssSSi.
ERT ICATE OF EXEMPTION fROM WORKERS' NO.OF eLOGS. _ n55E550R
COMPENSATION INSURANCE SIZE OF LOT NOW ON l0T MAP BOOK PAGE PARCEL
� (This section need not be completed i4 iha permif is for one USE ZONE MAP
hondred dollars($100)or less.j TRAfT 42556 B�OCK �or rvo. 18 No.
� T . _ SPECIAL �
I certify that i the performance of the work for whi<h this OWNER$jj[�T'f(�j,�(� j,ir'jIj$D CON�ITIONS �
permit is issued,I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BV �
A�DNE55 3151 AIRWAY AVE. SUITE N corvs� � �
so as to become subjecllo ihe Workers'Compensation Laws. !�
I ciTv COSTA MESA CA. zia 92 626 � �� ��J �
I Dafe AppliCanf — STATISTICAL CLASSIFICATION APT. CONDO.
ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of 6.!
mption, yo� should became su6ject to fhe Workers' ENGINEER NO. CLASSNO.�DWELLUNITS � i
I �npensa�ion provisions of�he La6or Code,you must forth- qDoeE5539�JO WESTEXLY PL. ��170 NEWPORT BC �
with mmply wi�h such provisions or this permit shall be SEWER MAP �
� deemed revoked. coNTencToeBRAIL9LEA CALIF. NO 50— 001 BK NG, VALIDATION
� LICENSED CONTRACTORS DECLARATION STE.LIC.
I I hereby affirm thaf I am(icensed under provisions of Chapfer 9 ADDRESS 3151 AIRWAY AVE. N No.409610 VALUATION
i (commencing with$ection 70D0)af�ivision 3 of the Business and LIC. �� I i I �1
I Professions Code,and my license is in full force ond effecL CITV CL455 S
I 409610 B SQ.FT. NO Oi NO.Of CHEIX g� , � ° = ' ti[ 1
License Number i��.class s¢e 1637 sroRies z PAMILIES 1 oNe
I ^ � DESCRIPTION OF WORK Z.Z BR NEW �y b f r'G���(�y
Coniractar 1����B�
I ADD o � W�.z�,����;
I �I am exempt under Sec _
ALTER n FINAI IO J��
i B.&P.C.for this reason NEW C4NSTKUCTION REPAiR � DATE o7 � L�%�o�'���'
Date: USE Of FINAL
i ��� EXfSTING BLDG. NONI: DEMOL ❑ 8
Signature �Jl._.�_ � . APPLIGANT TEL Y
PRINT
'� OWNER-BUILDER DECLARATION N� — .�� � I [A
', I hereby affirm that I am exempt 4rom the Comractor's Lic se 3151 AIRWAY AVE. N COSTA �.'EL
�� Law for}he foliowing reason(Section 7031.5,Busi an P.�DRE55 � �,+v w u a� n �
' Professions Code): PReSENi
n BUILDING n
i � I, as owner of ihe property, or my employeei with ADDRE55 � °4 P�`^��!'
! wages os their sole compensation,will do the work and
� the structure is not intended or offered for sale(Section �OCALITY �f;ij{� ;j(�.-T:
7044,Business and Professions Code). MOVING TEL.
� I,as owner of ihe properfy,om exc�usively coMracting CONTRACTOR NO. �j 7,��«��
�� with licensed contranors ro construct ihe project(Sec-
tion 7044,Business and Professions Code). ADDRESS
REOUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YAR� HWV PROR uNE wIDTH ►
I hereby affirm that there is a consiruction lending ogency for FRONT
�he performance of the work for which this permit is issued P.L.
(Sec 3097,Civ.C.j. SIDE
Lender's Name
TORONTO DOMINION BANK P'�'
� _7 ,�
Lender's Address SAN FRANCISCO��CA. 94104 P.c.Fee� �t�a-63 Pe�m�r Fee
� I certif that I have read this a lication and stote ihot ihe
Y PP �ssuance Fee �G"��v
¢ above informafian is correct.I agree fo comply with all County Investi9arion Fee � �
� ordinances and State laws relating to building construction, ro�al Fee
and here6y authorize represen�afives of this Counfy to enter
� upon the ahove-mentioned properl for inspection purpos s. � /o� p��� �
n 1�1+,..-r . o r �7
tQ � 8 SEE REYERSE FOR E%PLANATORY LANGUAGE
Signature of Applicant or Agent Da�e �s
--_______._.�_--.- --..____._�______..._____.�.----
� � �� � � _._` p � —�l�i-..�
m T (!'_ r r. m �s U! -rt r � U� :4°J � � � �1 2
�' o o ° °� 'n o ° l� ° � ° o.� o m --� fl a fl �°� �'
�° „ � S �,-'�; .,0 3 � � I�� � ? o � n � � � f i o i Q � s �_._...� �
p b T ! C7 `� N fl �� O � I � O � � .� � f0 ' N .` i
� Z x {fm� � - i x� Z"' � - o � �' '� Q p ry �
T �� � I O Q C � � I �� b � � O"O p � f � ~ � -Y '3
O I _ � 'U — � O ._
7 I N � � — P �Q � 6? � � O � G � I � t� � .
Q , I ' O I 0. �. '/+ � � a .� m � -. � ro q � { ��
1 �c, "'y
-- , �`----'i— ' �J 3 � J � � i 'I � �
-��. ' F � � c,L • l �j ; I _a. ... � �
� �
�, ;�.,�. ��;�. ; � - � � - - - _ ;----- -.�-=,-- ► ��
�___ � �
�. 1�l�� �_- I I� � � �
�, .<, �e �,, ; � � I ,� `'
, '�:�� � � � �
-- — _�L�_�—�-�•'"o-���-- � �" .� �, �
��� � �
�' � ���"'- � ' ,- �- _ =
i � `3 � I � � � a � �' � m z
( �
i � � � �� � -� 1_�_� --- - -�- � �
I � � �
, �
� � � � �' .. a�
I � � ` � $ � '
� � �
i ' � • j s ° q
� � _ � �a I �
, i � � , � . �.
�._._�.__�._.__�_. __ ____ _ �.__ __ .� _ ____ ____
' i � � ' � _ __ � � � ' � �
� � � }
1 � ; � ; i , , , , ,, �
� ; i � : , � . .. . ' , ._ �.
I � � r f _
i � ; . ' ; ' .
� I , _ , � � � _�
� , I � � _. f � � T�
�
; , . ��
� � .� � , ��
. ' �
i I � , i , . ' . � � ; � �I � , - �
� � i f i i , I - . l � � i.y
i � i � � . _ i . � , . I - .
E3 � � : �
I . F� . _ f
, � � � �
� �� �
I � � : , �
, , � , � � , ,
� � i � . � ! � � � � � i
i � II � � � � � � I � , : � � � �
. � � � I
_ - I � . � I e8 ; G n'7 �� '� _ �w`� wb !• • +��=� � ^ �.!'�^^�,-e o" " � �, � —_
, � ._ � � Q � -, � � �•T O ' u c'� J V V A C (n 4 .- � S . J .1,.1` R q ��.(,.�'. n
� .7 � µ,Q h A�V �� f0 y � � � ? �..N p N �p .5�. "'t ? C.� \'T, ll n S
I ! .n o v ���� F � � � � �`. A,� _ � .� A.,,,n w�.,� �,�,� M y' � �
� � ..` - ., -
i .�• A '� ryy_ � a �V �c ,� %: n ",L'^.;�, � e"� `�v A �+�i N CJ
I ` � ' � � _� �. � �- � � .,, � rc � �" .' � � " ��� " Y � �
��I_ 3 a �...,,.'� �. O w V+Y �� �.4� �, v c p ti..p V .."�-,� � A. !a o'� O�
I - � . � "� m .V v_�'� . rn o q y`,,.� ^ A , �c.. „y' m o „s � ��n� a �.. ���tL E � /
� �. m �.a � � � m � �y�.��n z: �ti v � � -•y �� 'r' ��e ` K � ;zl
� . !' j �. 3 �' � " „ a ��o � � ^ � A� o o c� � � � ,� � ,,,�n � R:�?, � �
I , . � . 'o ' .� m �� c�� O,� � � ^�'_ m � � x . y n �-� ~ —
I, c,,o °, ` � h ��^ ' o � ^` e: �'�r � � �
s � -a
1 I I ' I ' � Q Q � ;i � 3' � r .w.wy � ^' (G O S,e � .`�", S�:-�y S� j` n � '�-�+
1 _ . . ' - A �-"�S r (9 ^ T V. .., � A � � � , A p;C �# Y? N ..�
I,`�� I � � ��:� 'v�„'��o 'a .�.2 �S "�N a � � r'�� p'A c �� � �� �� "�'9
� �� � .. �i.- i � . I � �q^`�a I °n `� � " ":� «_.� � �.� �� �a `ri � �.a��u� o :,'n ; � f x �
� .. I � _ � 4 I ; x � �, o �,� �„- �� a . m w� � � � h, o �. � a j :�
� I I. , `41_ �n � � y , �f �-: � -� � � �..y ��o M M1 io ;zi
� M r,c `�+.�.r'. '-�c 9 ^m� a w �r�p� s ro �
I C) ,I � ° o v�o a '` � ti,.. � tr �'e
t + � 3 -.,�. _ �ti, m s o ,�" o .. .d ,� ��,•�i � io
I' f "a ij a� rCy�'-' � .��J ?Q._' r �``�:,A S p ' . Q �'.T.
� . I..� ' I � ' I � y '. n .� .q^�"y A.n =? —� �A`�n;3 y' � A p N ,� � �'1
� ] i .V � O .1 +,, �.o .,y'."..-- n F•.� '� c S'� � a o� �� n 0."-,� „' h,n,`;�"� � 3 i�
� � _ � _ � ; � � � Y �� s C - : Fr� - �t � y (D �,.,�N. K A'-S'�•.A � "�. �c �-^
i Oo �[ ��;'� C` u �t '�' �; J O ? • M �2 _�1„ EY S r, fp
'���e �.-p �' ,�0.V,ro 't�L �p S Z A Q �?'LY..��n m p�,� o [/�
� � � s N� � �.� � �p.� w ?'uw y..(A� � �^ C� �?'��d R,.�X ^ o `�
I n v a-�. n 0 d C �A n.� C h^ ° N �� ti�,�2''� �p A '� � � �I�
. . � o ^ �`r � ` µ � '� �c��m n n'�'� �A �°t w =` '� �,� W fl .
I ��•, I. .. . �
i n o -r„n L^
Nr` � � cD Q ^.^. O '°�,,�"'•� � ❑ `� �ro �v O ,� O,m Y' N' ;�• O
i
I � - �S O i'n n ., u��. `�t y�'� � �T `�;�GP ro � ^� � K N �u�v+