HomeMy WebLinkAbout1111A 1112A (5) 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 ! 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