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
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