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
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