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>.
Signa��re of Applicam or Agent Date �°
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