HomeMy WebLinkAbout1087A 1088A WORKERS'COMPENSATION DECLARATION �
I hereby affirm that I have a certifica�e of consent to self , �
insure,orace�tiFicpteofWorkers'Compensationlnsurpnce, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof(Sec.3800,Lab.C.)
Policy N�1WBRK�+�+S�+Company �1RTFORD GROUP L�UNTY OP LOS ANGELE$ BUILDING AND SAFETY
� Certified copy is hereby f�rnished. FOR APPLICANT TO FILL IN ADDRFSS I �� L�` —•�/' � �
NRl Cer�ified copy is filed with ihe munty building inspec- BUILOING e
`CJ lion deparimenf. ADDRESS 1438 S. VALEVIEW DR. �ocnurv •� �
NEAREST
ppte Applicani y..�-��-- CITY ➢p CRo5557.
ERTIFI ATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This sectian need not be completed if the permit is for one TRACT 42554 BLOIX �OT iQ U5�l,�fJ€ MAP
hundred dollars($100)or less.) d NO.
TFL �0�4� SPECIAL �
I certify that in the performance of the work for which this OWNER BRAMALEA LIMITED NO.$rJ�-10�1 � CONDITIONS �-
permit is issued,I shall not employ any person in any manner 3151 AIRWAY AUE. SUITE N o�SiR�Ci GROUP ivve Flke PROCESSED BY �
so as�o become subject to ihr.Workers'Compensation Laws. P.DDRE55 CON�
�
arv COSTA NiESA, CA. ziP 92626 �p �=� • C3
Dafe -ApPlicant ANCHITECT OR TE� STATISTICAL CLASSIFICATION APT. CONDO. �
�"'1TICE TO APPLICANT: If, afrer making ihis Certificate of nl �
yipfion, you should become subject fo ihe Workars' ENGINEER � NO. - CLASS NO. �/� DWELL UNITS� �
� _.inpensation provisions of the Labor Code,you must forth- qDORe55 3990 WP',STERLY PL. I{'l�O NF,WPORT B va
SEWER MAP
j ith comply with such provisions or this permi� shall be TFL �
deemed revoked. VAIIDATION ��
CONTRACTOR$�N CAI.IF. No. -1001 BK. PG,
I LICENSED CONTRACTORS DECLARATION S E.UC.
I hereby affirm ihat I om licensed�nder provisions of Chapter 9 ADDRESS � No. 409610 VAlUAT10N
� (commencing with Section 7000)of Division 3 of the 6usiness and ��C.
Professions Coda,and my license is in full force and effect. C�TY COSTA MESA CA. 92626 C�P.55 B E , � �� '
409610 B s�°zeFT 2542 sTOR°s 2 Fn°,�2°,Es 1 CONEK
License Number Lic Class
BRAMt�L�A CALIF. i�,�� NeW � s
Contrac�or Date DESCRIPTION OF WORK �-'� (�s.`�1;
❑�am exempt under Sec. SINGLE FAMILY RESIDENCE A�ER � FINAL , �" ` ° "2�
8.6P.C.for this reason N�W CONSTRUCTION ❑ DATE �c�/� � • j 8 I.� U
REPAIR
Date: USe OF FINAL
EKISTING BL�G. NONE DkMOL
Signature_ . APPLICANT TEL 7 eY / m ���� � ' G U
DWNER-BUIIDER DECLARATION PRIN7) $Y NO. $ -lOOl , �J(1�-'�j�
I hereby affirm thai I am exempt from the Co ' e
law for the following reason(Section 7031. , siness and P.DDRE55
Professions Code�: PRESENT
`1 C$8A
^:! I, qs owner of the property, or my employees with AD R 55 '
, wages as their sole compensation,will do 1he work and
�he structure is not intended or offered for wle(Section �oCauiv �'u o e s o '�
7044,Business and Professions Code). MOVWG TEL. I q��t �O
� I,as owner pF fhe property,am excl�sively contracting CONTkACTOR NO.
with licensed confrocfors to consfrucf�he project(Seo- qpDRESS ° 'E%��L V ii��
iion 7044,Business and Professions Code).
RE4UIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH , �1 7�O C-"H S
I here6y affirm fhat Ihere is a construction lending agency for FROM
the performance of the work for which ihis permil is issued p.L.
(Sec.3097,Civ.C.). SIDE
m Lender's Name 1 0ME g p� y
TORONTa DOMINION BANK P�
$ Lender's Address�� ���%15�pT.��SUIT�4 p.G Fee$ '�G�� � Permit Fee � �0..S O
>
I certify that I have read this applimtion and state�hat the issuanre Fee �U'���
a ❑bove informaiion is correct.I agree to comply with all CouMy Investigation Fee
� ordinances and State laws relating to building construction, 7oral Fee ���r Q v
❑nd hereby authorize representatives of ihis County to enter
� upon the abave-mentioned property for inspection purp es. �
` ��� -�. � ��� Gc:� ��--e�� �;,Ct''
SEE REVERSE FOR EXPLANAiORY IANGUAGE
Signature of Applicani or Agent Dafe �s
_�- ��
_`_---- � 1�; ,
!
_-5-- ��` � � � �I ` �
��
.�--" ;�,� ' ro � Q ro ' 4 �?. � � i
�r; ro �w� o ry o � � n ' ' 1
_. _- �'_�,. ^' �O ] P , G � > -p O (C ir ', v I
a 7 n � � �, V. - C cD ..;, � Yf .�w,
_..-- '"r-.--e� Ji�o' � � 1 _..n 4 ' Q Q n 1 9 � � `p
�r' T � c � G _�_^� .;'-_ � 4 1 S_� � -� � � �_� p ` �
-�--�Q � ! Q 6 3 ��o� v ,�p 1 a"G o � ' " � ? � a �
n,_!i n�� fl S � [ ' q �' wS � � o : -6 :a � � �
3 SL 'CS N W
� � � � i � � ' � �
, o � � ; � � � � � �� ��.. E xi
ro o�m N� ���? ' °3 �° ; � 4 �� o i . � ��. sn
� `�sw� % ,� � � , � � 1 ' � ° �
1 �� � ` t
O L �
L? Q t � QU✓.. Gl � �,...a.--""11 �, __,,,,,,,,JJ
� -�" �� '%' �
� .o� � � O ' , � ��� ` 1{-���y 4 �
° �m �
, 1....__ , `, _ �" � t
� ,�q ,� � n
F j .�,-�;�," 1� � � __.�--- 1 � � ' w. � � z
t -� `=^ ``°t-� ,� xi y..---___--�" ' � � � �� r+- .a
s_
-:."" ..
�_,_. �s�...`K�,v. ;��� � 1 _.� e �
'�---' � ��. ,�;-=._��� j 1 :. ' �
'� '� �1_ �
,_ ,�.
� �°����-� `�� � ` �-�---` -- . �� !
1 i- ��,; � .. �.._ -. "` u a
� . � '� � ,s
� ;� 1 �� � � ' , � �'�° �
� � ', �� � . <� I �-
�� � � �. � a. ' �'� 1
� � '�, � � �•
` ti �� �� � � L_ - -
�---- ,
; ' ! �' � � �..-. �
� � �_ __- � , .._ . � ..� ., ,
I�_.._�_ `- , - �. ��= �.� !:�._� :�. 1, ,
' �. --5— i , i ' � � � i
- � , � t _ � � 1 1 �
� � ' � i� _ � � 4 a
, � � I _ � -�s , , � . � � �
� 1 . � � � _ ' ► = : � . N
� . � �.
., � , . , � ��
� ` � , I � . � � .; � ��
� � � � l: .. ;� .. � N�
� . �- �� �; . ,
'� , I � - ; �; 1 - . � � � � _
� � � � � : ,- � :. . .� :.
�� - ' _,�, _ . t. �` . �
� 1 , � . � , � � 1 �
� ► .��. � � '
I � � � -:.
� � ' -�:= T.
, ; 1 ; :
� } , . _ � � _
4 { c,.� � i w � m
j n C�^�.�; K a �v 3 �
' �.. �_.'� � ,1 ��..x` ,:j"...p..� A A � 6
i � � - �., ...'tl� ry^�R ' �p � .. � ti.S _'-�7;�� r.'� fi�A rrj �-C
� ' ' '�' � �' S� � ,� o ;' ~� N �~�� ���� � � { -
� p � y � t�.N c - . . .,M�� �- ."'?
.,-a � o�, r-�,� � M V;�,'q � N ^ N e "'�A � 'so,y � �, "q 3
{ ' o a• �o •%� .w � ...°,:a�� ..'° a a � .. x N .. ^`"4�n y�`�� '.c ° �'�
y � � � G ? u � ���,:• -. _- � -s ,�-� : � N Cd O M�"� � r. co ^t ,i�' r:`-+, 5 CS�+
' 1. . , � � C O _ � pn`��x' p M� �"°,,,H ✓; ,�r�'�� '_ !G � ^,^.`�S,'A' ...S+. . .r'-. �-� S� C
4 "C� N 3 � � S.` F.` Q W
¢ i� Q �-' � � i o 0 0 �a-�a o ��r � o � Y A � Y '� a �.�,J, � � ..+
. , lS '" ' ' � � '1 3 �, R,�'� '�9, � `,`�.M,�,." � ^'� N . m °. m ;�_,x'c� �`_"�^�r^s °3 C�'-":
� 1 � '`, N ,..."~ pR...., `^V� A � C..:3 � l w �. p ,-.�,..-Z � ��u�c ,f',4 .'�..-Z � O �p N
� '� ¢ u 3 � o'� �.m c o� � �" A v.'; x.�.�:� s � � 's.. 'z x r-�
� � ' § �_. � � ^ �:, _ C.,� �" ' m' .,'1�'�+ -� � Q �n 0.�6 � S '� '"• 4 � 'c' � N '"
' _ o � � `� � � @ � ~� C .�,.' .. � C�
� ; 3 , ^ �� '.�? s� `� "-�e M b n'x t�a�o �'�,fi�� "'' �,:"`¢ -cs
I 5 '..�' �, � ^ f� �•ie ..+.(°a'r. �; C O p N -p Xw. .., �j �y ?
C �=t ` .q.,�,.�,.'O • .. :' x�w "'� A�' Q.tD, .e n. ^.�.,. ,L��.=i?�- �p "°,✓
_ � %� � � '' ^ '�,Y' � ., ,.�,:� � � m o o � •,� n � � �^. � c � �; o� a �
' ;:�� , . —� �µ;.;. � 'r� � a. ��v �� ,. o � �� � �, � � �e � � '
; ki;� :�� 'J• '_� ie. , '� ... , V
1 � ',"5 (D �R.:«`;t,. � s i °3. q N '.R°,'�w t0 N �L �' � a 1'� �Y,.�.4 v ".��+, ,,,�q � �
-G Q � N �
� '� n a ` n -^� . '� C`� �� Q'„�s m A' :s�C�a - N
'l 1� � ,' .� �'O ^l�3 ��'� '`�'�.'�•�y� ° o m ��d.-�x.t�,:a•� �.¢,.""'�� � o P
� -''' �� , :� � . � _.- s� � ...•:o` r a-..� c� � Q 3 �^ TM r„�.a„ v c` ?
' 1 ��, '..1 � �° � .. r� n t'"'� `� A.r��i `c�« co m Y= � ti ��.'�"' U°.� �`� �°
i � _ ' . �+ Y .. o ,.r� � o -•� o .v •�'-, �•e � w�
1 • �f�1� ., ' � Q �m m, N , ry�o�. �.� o "v+� � �s;•� �•`��-�' s �, o
' �i�.� 0_.1_ ; �r � z ,� ,'�` � .� ,�� ° m .�-.P n r..�:r n K _ � y` u�
� ' £ � �? n _ �-o rn V 3,�. � � F w Q�vt� � � �.e�
� .' �' �' `^�'° 'k C t, " p T'%o �'io �A C�4 $ ».� � %F•
� � � � ":.�-,.� =� `� o � � '� n Q.s`
:'� ,(7 " � .,� iS .�i 'q M M ,�q � .✓/K
� n T� �... .`-��� • ....�-..�-..'
� '� .. I � � � � C D n � y �fG � �'..-._I
, � �' .+ - �
� 1 �„ ' T � � ,,,.r--
. �j ' ` ' � � N
1 � � � .�-,�"���^
t � 1 � --.—"`'�_
1 < <.._------'"'—
�----....--
.....----�''"—�-`'�^.