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HomeMy WebLinkAbout1097A 1098A � WORKERS'COMPENSATION DECLARATION � I here6y pffirm ihqt I have a cerlificate of consenf fo self APPLICATION FOR BUILDING PERMIT � insure,or o certificafe of Workers'Compensation Insurance, or a certitied mpy thereof(Sec.3600,Lab.C.) CpUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNafil[dP.RK4�+84Company HARTFORD GRDIIP BUILDING Certified copy is hereby fu�nished. FOR APPLICANT TO FILL IN ADDRESS :�2- r' � Certified copy is filed with the munty building inspeo- BUILOING i�o deP riment. ADDRESS 1431 S. VALliVI�W DR. �ocnurv •��' �are n I�canf aTv ➢IEll�10ND BAR NEaREST pp ZIP CRO55 ST. ERTIF CATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION WSURANCE - SizE OF LOT NOW ON LOT — MAP BOOK PAGE PARCEL (This section need not be mmpleied if the permit is for one US ZONE MAP hondred dallars(Stoo10�iess.� reacr 42556 aiocK iorNo. 19 ��, No. TEL SPECIAL 3� I certify ihat in ihe performance of Ihe work for which this OWNE EA LIrLrTEn NO 5�— ��1 �-6���C7 CONDITIONS sY. permil is issued,I sh61I nol employ any person in any manner 31 rj 1 (-�IR�p]E;Y [�VE+. SUITE N DISTRICT GROUP iYPE FIRE PROCESSED BY 6� iso as to 6ecome subject to the Workers'Compensotion Laws. �+D�HE55 ,ry ��3 CONST�7J� Z 3✓ i arvCOSTA MESA, CA. z�P 92626 �� V � Date Applimnt STATISTICAL CtAS51fICAT10N ` APT. ONDO. i� NOTICE TO APPLICANT: If, after making this Certificate of a.RCHiTECT OR TE�- � ywa mpfion, you should became su6ject to fhe Workers' ENGINEER NO. _ CLASS NO. r� �WELL UNITS� � i ,�npensatian provisions of the Lahor Code,you must forth- qooaE553990 WESTERLY PL. 4dll0 NEWPORT BC SeweR rotnP '''� ith comply th s�ch provisions or ihis permit sholl be � � deemed revokad. coNrencToe No.� —1��1 aK. vG, VALIDATION I LICENSED CONTRACTORS DECLARATION � i I hereby affirm ihat I am licensed under provisions of Chapfer 9 nooaess3151 AIRWAY AVE. N ' r`,',o.40�9610 VA W ATION (commencing with$edion 7D00)of Division 3 of the Business and LIC. ` i V(�,'�Fl iProfessions Code,and my license is in fuil force and effecL CI7Y $ A CE]. C�q55$ $ � Q� , '� i 5(,�.FT. ND.OF NO.OF CHECK �:s a • e�'� Licensa Number 409610 Lic.C�ass R( SIZE 18$ STORIES Z FAMILIES]. ONE � ConifaCtor B�iT�LE'A CP.LIF'' pate��}�_ DESCRIPTION OF WORK 23 C NEW � � i 8 3�Q 4 1 II ❑I am exempt under Sec � ! ID�NC� ADD � d "�%0 4 1 T AtiER � PINAL i B.&P.C.for this reason NEjd CONSTRUCTION DATE �]p'�(a 0 7�(i G—8 5 REPAIR � y US[OF DEMOL 11 Date: FINAL � exisnNc aio�. NONE eY i Signafure � � OWNER-BUIIDER DECLARATION APPLP NT)BRUCE L. ABBEY N — 8e1 I hereby dffirm fhat I om exempf from ihe Conirat ice nooeess 3151 AIRWAY AVE. I�1. COSTA , `� e 9�`A i Law for the following reason(Section 7031.5,Business and � Professions Code)� PRESENT {�a � • � • � � BUILDING � I, as owner o�the property, or my emoloyees wi}h ADDRESS II i wages as their sole compensation,will do fhe work and � P1�%�!y.��U � fhe structure is not intended or offered for sale($ection l0[ALITV I �h 7044,Business and Professions Code). MOVING Tft, • €�'�����:�i�)_ I', �;7�� I,as owner o4 Ihe property,am exclusively contracting CONTRACTOR NO. �, � wi�h licensed contracrors to construct ihe praject(Sec- � ��n�—�� '. tion 7044,Business and Professions Code). AODRE55 CONSTRUCTION LENDING AGENCY REQUIRED YARD HWV TaTA�SE78ACK FROM EXIST SETBACK PROP.LIN WIDTH ► I hereby affirm�hat ihare is a mnstruction lending agency for FRONi the performonce of ihe work for which this permit is issued P.L t5e[.3W7,Civ.C.). SIDE Lende�s Name7'OP.ONTO DO�INION BANK P� s 114 SANSOME ST. SUITE 700 p,C.Fee S ��• 1 Permit Foe V�•J� � Lender's Address 4AT�I'R11Nf ISrn_ C:AT,9G1(1/� /O �� � I ce�tify that I have read Ihis applica�ion and state ihat Ihe Issuance Pee / m above information is wrrect i agree to comply wifh oll Caonfy Invesrigation Pee .` g ordinances and Sfate laws relating to 6uilding constroction, To�al Fee ��"�"� L� and here6y authorize representmives of this Counry�o enter � � upon the above-memioned property for inspection urpo es. �e �O� �,-0r„� a � �_ .iV ��V J SEE REVERSE Fp E7CPLANATORY LANGUAGE n �iqnature of Applicani or Agem Da�e � �s _--�—___�__ _._.._ _ -—- - - -- ---- --- �_._.___._._._.� �,�n� � j �� _ -n cn --c,�^o�--- - ---�-�-!�•-o�---f,_��_...�_I_.� T � � 9�c o I � o o � � � � ; c � c ..�� �.. , 1 (� ci � � Q � � � � y �� �� ,�a O � � S s _? � � � 3 �-� ` � � � � n � � � =L � � � .� ��. � o r., �u ' m ��o � �' I � z� ° � � � 1 � e �� c�� � � � s � I . = 7 x � - R- j _ � � � � a i I � �� � �O.£ C y' � I i � � �N Q 3 ' � � ! � N � �� � o N 3 E o � ' � c i � � fl zi � �w 3 � - I �� �� Q � Q � �Q � � � � `= U � � Q Q' � b i7 � � i � � ��; � � o� ; �� Q , v� � @ ; � � � 4 � i -� j �-- ; ; � �� J � �. � �; ��-- -- --���-���.–�___�_ - .--. ! `° -�- ti.. ; � �.l�.-�;-�-�-- � °- � � t i `�'.��„ i�v.� 'i`�'r' I � I I _ cQ �_.—_L_-• - �.---- � � � � C� �.:�� --1 —�- � � �- � ��� ��`. �..� � � ^� � � � � � o i ~ - � � � '�����✓�- � i l I .A � �� �m _____�___._: �� Q � � 4 t I ` �I ._ _ __ e' rt � � '�� �. � I.. � ' n � � i ' ' � � � c" � D � � � � �a � o r� i; ' _ �_ o m' � � * �. ! 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