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HomeMy WebLinkAbout1081A 1082A WORKERS'COMPENSATION DECLARATION �� insureboraofcerlifca'teofWorkersr}Compensatioo�lnsuranelf APPLICATION FOR BUILDING PERMIT r or a rertified copy thereof(Sec.3800,Lab.C.) Polic NJ]Lial3RK4484 HARTPORD G20UP COUNTY OF LOS ANGELES BUILDING AND SAFETY Oy Company Certified copy is hereby furnrshed. FOR APPLICANT TO FILL IN noDREss � � �</v`+-v�✓ °�R' I-1 Certified wpy is filed with ihe county building insper BUIIDWG .,�� DU tion depariment. AD�RESS 1435 S. VALEVI�W DR. �ocaurv NEARESi oa�e � Applicant ,..�. aTv DIAMOND BAP� zia ceoss sT. ERTIFI ATE OF EXEMPTION FROM WORKERS' NO,OF BLDGS. ASSESSOR COMPENSATION INSURANCE RE OF LOT NOW ON LOT — MAP BOOK PAGE PARCEL (This section need not be completed if the pe�mit is for one TRACT 42556 BLOCK LOT ZD USFyjOJg� NOP hundred dallars($100)or less.� l�`�� :, TE � SPECIAL I certify thaf in the performance of Ihe work for which this ��'NER BP.AMALEA LIPIITED N — ], �d� CONOITIONS �• DISTRICT GROUP TYPE FIRE PROCESSED BY �✓ permit is issued,I shall not employ any person in any manner � 6} so as to bewme subject ro rhe Workers'Compensauon laws. nooeess 3151 AIR4v'AY AVE. SUITE N `� �_ wN� �e ,,u � 3 �/ `�� aTv CA. z�P 92626 � Date AppliCant STATISTICAL CLASSIfICATION APT. CONDO. �^• ARCHITECT OR TE�. 4,� NOTICE TO APPLICANT: If, afier making �his CertifiCate of ENGINEER BL�SrJ�'NJ�T No, 52— 864 CLA55 NO. a� DWELL.UNIT$�' � ' ption, you should become subject to the Workers' � �pensation provisions of the labor Code,you must forth- qpoae553990 WESTERLY PL. �F170 NEWPORT B SEWFR MAP � with mmply with suth provisions or fhis permit shall be —• deemed revoked. CONiRACTO LEA CALIF. ni�. —1001 gK� P�- VALIDATION LICENSED CONTRAQORS DECLARATION . uC. �hereby affirm ihaf I am licensed under provisions of Chapter 9 nooaes�151 AIRWAY AVE. No.409610 yq�UAT10N (commencing with Section 7000)of Division 3 of ihe Business and LiC I I� Pro4essions Code,and my licensa is in full force and effect. CITY 2626 CLA55 B "� , 409610 B s°eFT 2144 sTOR�s 2 °i°es7 oNEK license Number Lic.Class ComracrorRRAMAT.RA CAT.TT' Dare��.q� DESCRIPTION OF WORK 24 CR New � �' �I �'8.1 R �I am ezempt under Sec. l ' DENCE ADE� � F�NA� � e � " °�1 8.8P.C.for this reason NEW CONSTRUCTION REPAIR � DATE ��o f f��e � v�z�tG��� Date: USE OF DEMOL FINAL g � EXISTING BL�G. NON� � By �<.;:'i�;:��� Signature APPLICANT TEL. , ` OWNER-BUILDER DECLARATION PRIN7) N — OOL , G��Q C"�1 v I here6y affirm that I am exempt from ihe Controctor' ¢e � ADDRES �1$l�[:Y E1V�. IQ L'+�.5`�A I�'E1a�+'A. Low for the following reason(Section 7031.5, 8usiness ond Professions Code): PRESENT BUiLDING .�:� C R�L A n� I, os uwner of the property, or my employees with � AUDRESS wages as their sole compensation,will do the work and �'m a • • o � ihe strocture is not intended ar offered for sale�Setlion LOCnuiY I;-f� 7044,Business nnd Professions Code). nnOviNG TEi� � p 5�y&C� 'V� I,as owner o4 the property,am exclusively confrpcting CONTRACTOR NO. �"D*' with licensed contradors to construn the projeu(Seo- e c����i,(j(;T tion 7044,Business and Professions Code). ADDRESS REQUIRED YARD HWY TOTAL SETBAIX fROM E%IST. , O�I,n�"�H J CONSTRUQION LENDING AGENCY SET BACK PROP.LINE WioiH I hereby affirm fhot there is a conslruction lending agency 4or FRONT the performance of the work for which this permit is issued P.L. �Sec.3097,Civ.C.). SIOE P.L. Lender's Name TORONTO DOMINION BANK � Lender's Address� F��CISCO,�CA. 41 P.c Fee 5 ���a 2• Permit Fee S��'� � I certify that I have read rhis application and state thm ihe /Q'`•' V Issuance Fee ¢ above infarmation is correct.I agree 10 mmply with all Counfy Inves�igoYo�Fee �^ `� ordinances ond State laws relating to building consiruction, io�al Fee °'������ and here6y authorize representatives af this County to enter � upon ihe above-mentioned property for inspection purpo es. tOi1 �� �,u ,gs� _�9��,/'�.,,r � --F� yci,i d—�i�x �.7.f n ��.�1 SEE REVERSE F�E7fPlANATORY LANGUAGE Gt>. 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