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HomeMy WebLinkAbout1105A 1106A (5) WORKERS'COMPENSATION DECLARATION � i hereby affirm thal I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure,or a cerfifimte of Workers'Compensafion Insurance, or a cer�ified copy thereof(Sec 3800,Lab.C.) GOUNTY OF LOS ANGELES BUILDING AND SAFETY Pou�Yrvo.61WRRK448�ompany_H1IRTFORD GROUP � Certified copy is hereby fumished. FOR APPLICANT TO FILL IN BUILDING � ADDRE55 1��' a ��-✓�� RXl Certified copy is filed with the wunty building inspec- BUILDING � p L-� tion depar}ment. Q ADDRE55 l�+�t2 S. VALEVIE[tiT DR. LOCALITY !� IDate��J�llppiicant �.�=1�C. CITV D .'� ZIP CROSS 87. I CERTI ICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSE550R COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT — MAP BOOK PAGE PARCEL j (This saction need not 6e mmpleted if the permit is for one US N MAP � h�ndred dolla.s(S�oo)or less.� TRACT 42554 BLOCK ioT 9 �t�c� rvo. TEL. ���g SPECIAL y I� I certify that in the performance of ihe work for which this �wNeR SRAt4ALEA LIMITED NO$ — � CONDITIDNS if� ' ermit is issued,I sholl nof em lo an DISTRICT GROUP TYPE FlRE PROCESSED BY �� p p y y person in any manner qooeess 151 IRGdAY AVE. SUITE N coN� z �+ �, so as to 6ecome subjecf to ihe Workers'Compensalion Laws. b .�' ,y, cirv COSTA M�SA CA. ziP 92 � � , Daie AppliCaM STATISTICAL CLASSIFICATION APT. CONDO. P'� ARCHITEQ OR TEL. ,y-� ) ��, ^'nTICE TO APPLICANT� If, after making this Certificate of L�R[1i�1 S�SSEIQIEIN 2-1 CLASS NO. DWELL UNITS ��, �nption, you should bacome subjeU to ihe Workers' ENG�NEER NO. V V / � j ,mpensafion provisions o4 fhe labor Cocle,you m�sr fo��h- nooRess3990 WESTERLY PL. �k170 RT �C SEWER MAP "�� with comply with such provisions or this permit shall be � � li deemed revoked. coN7enCTOR BRAj1AL�A CALIF rio850-1001 eK. PG, VALIDAYION � UCENSED CONTRACTORS DEQARATION I I hereby affirm that I am licensed under provisions of Chapter 9 qooee55 3151 AIRti+,TL�1' f�VE. STE��, 409610 yp�UATION '�, (commencing with Section 7000)of Divisioh 3 of ihe Business and LIC. Profess�ons Code,and my license is in full force and effect. ciTv COSTA MESA CA. 42626 c�nSS B S Q � ' � SQ.FT. NO.OF NO.OF CHECK : I � C�Fi License Num6er 409610 i;�.C�ass B size 1884 STORIES�L FAMILIES 1 oNe Coo�mc+o�ramalea Calif pa�e DESCRIPTION OF WORK NEW � S rF s o o e�'� SINGLE FAMZLY RESIDENCE °'°° � � '�:'0.G.i �I am exempt under Sec. ALTER � FINAL � B.BP.C.for this reason NEW CONSTRUCTION DATE �i7/�(o • �3%�v L�'I � REPAIR � Date: __ USe OF oEMOI BINAL C 1.C G—�� EXISTING BLDG. NONE ❑ .._- Y Signature _ APPLICANT TEL. OWNER-BUILDER DECLARATION PRiNT) BRUC� L. 11BBEY No$50-1001 I hereby affirm that I am exempt from the Contracfqcr.� 92626 Law for the following reason(Saction 7031.5, Bu�iwess.a d ADORE 1 AZR�Tl�Y (1�1$ N C ' E� �,'F� ;�� � C(�� Professions Code�: BUILDING �,'.e a � o s � � I, as owner of ihe properry, or my employees wifh ADORESS � wages as iheir sale compensatton,will do the work ond �OCAtITV � s��l C!Q C the structure iz not intended or offered for sale(Section 7044,Business ond Professions Code). MOVING TEL. � I,as owner of the property,am exdusively coniracting CONTRACTOR NO. � �'������Q(�� wifh licensed contractors to mnstruct the project(Seo- qDDRE55 � 1.Q�-`��` tion 7044,8usiness and Professions Code). REqUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK �'4R� Hwv pROP.LIN wioiH , I hereby affirm fhat ihere is a consiruction lending agency for FRONT ihe performance of�he work for which this permit is issued RL. (Sec.3097,Civ.C.). SIDE �ender's Name TORONTO DOAIINION BANK P�' � 114 SANSOME ST. SUITE 70Q p.C.Fee$ � / Permit Fee '�-'��•Jz Lender's Addres J � I certify that I have read ihis application and state thm the issu ce Fae `�� �� ¢ above informafion is correct.I agree to comply wiih all County Investigaiion Fee an �j��'%iv„l T �' ordinances and State laws reloting to building consiruction, Total Fee l 7 � V u and hereby autharize representatives of this Coi�nty to enfer � upon fhe above-mentioned properfy for inspection purposes. � �� �.y Q � �09 y�} �.� SEE REVERSE FOR EXPLANATORY IANGUAGE n �APPlicant ar Agent Dat �f 7p— m-n r r� rn -n �Vf � T r� ' �'__--••�__��.. _r.4'��1"" � '_� "T _'.;y— ��� � 3 Q Q 7 O i Q O Cl'D fi p O _ ��c ° c ` � 5 i � 'o � i c_�m��� ._ � X a o � s� € � � •. �; Q�Yo �� � � �^ li � - �; -�� cn 3 3 cr�,1! � . � o I n n n �' I Q: l7 j - m I� � O �.� m J G� '� � a Q o � � � � � Q �.< j c0 3 [a i �' li ui ,� Z �� — �'� � � � �j n' � � � C �'• II �I O �C' O o Q Q I � Po � i � � I Sa � f�'u � 'O ' e Q I U �'' li � ! 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