HomeMy WebLinkAbout1113A 1114A WORKERS'COMPENSATION DECLARATION (
I hereby affirm �ha,� ha�e a certificate of mnsent to self APPLICATION FOR BUILDING PERMIT �'�
insure,or a certificate of Workers'Compensation Insurance,
or o certified copy thereof(Sec.3800,Lab.C.)
PolicyNo.61WRRTz448l�ompany HARTRORD GROtTP COUNTY OF LOS ANGELES BUILDING AND SAPETY
� Certified mpy is hereby furnished. FOR APPLICANT TO FILL IN nooRE55 /� � ,
�,y' �+ :
��`-.11 Certified copy is filed with Ihe munty buildinq inspeo- BUILDiNG
4Y tian deparimenl. A�DRESS S VALEVIEW DR. �ocnuTv ��� �
NEAREST
oa�e nppum�r . cirv DIAMOND SAR zir ceoss sT.
ERTI ICATE OF EXEMPTION FROM WORKERS' NO.OF B�DGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT � MAP BOOK PAGE PARCEL
(This seciion need not be completed if ihe permi�is for one u5e zONE MAP
hundred dollars($100)or less.� 7RACT BLOCK LOi NO.$ NO.
TEL SPECIAL 9-
I cerlify that in the performance of ihe work for whi<h this OWNER N — ��1 CONDITIONS �
DISLRICT GROUP TYPE FIRE PROCESSED BY �
permit is issued,I shall nof employ any person in any manner ADDRE55 � `f,'$ N /� n� CO� Z �
so as ro bemme subject ta ihe Workers'Compensotion Laws. � � � �
aTr � TA MESA CA. ZiP 92626 �
Dofe Applicpnt ARCHITECT OR TEL STATISiICAL CLASSIFICATION � APT. C DO, �
n'r1TICE TO APPLICANT: If, after making this Cenifimie of ��,— 864 ClA5SN0. DWELI.UNITS�
y ENGINEER ARAM BASSENIAN NO. �� w
;{npfion, you should become subject fo the Workers'
�hpensa�ion provisions of the Lo6or Code,you must forih- qooRe55 3990 WESTEKLY PL. ��170 NEWPORT B SEWER MAP �
with comply with such provisions or ihis permit shall be 7EL �
deemed revoked. WNTRACTOR I' No - ��], gK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION �,
I hereby affirm ihat I am licensed under provisions of Chapter 9 r.00aess3151 AIRWAY AVE. N n,o. 409610 yALUATION
(commencing with Section 7000)of Divisio0 3 of the Business and ��C. 2`� .' I � � v�
Professions Code,and my license is in full force and effecf. CITY 2626 CLA55 $ � ZJ�p
40 6 � SQ.Fi NO.OF NO OF CHEIX , t� ° ° • �'C�
License Number �_Lic Clpss R SIZE STORIES fAMILIES ONE
� DFSCRIPTION OF WORK ?,Z B NEW t�al � ' p r f'��C y'
Connactor BRt1PfALEA CALIF Date_� a ir'>-
❑1 am exempt u�der Sec. SINGL� FAIIILY RESIDENCE ADD � � u��``_
Al7ER � fINAL
g.BP.C.for this reason— NEW CONSTRUCTION DATE I�j� �(o C!C�-°�
REPAIR �
Date: USE OF D fINAL �
EXISTING BL�G. NOI�TE DEMOL BY
Signatu�e V�""-�-� APPLICANT TEl
OWNER-BUILDER DECLARATION PRINT RUCE L. ABBEY NO$SO—LOOL �,j � �_U�y
I hereby affirm that I am exampt from the Contractor's � nse qDDRESS � TA N�'SA CA.
Law for fhe following reoson(Section 7031.5, Bosiness and �{.a a a . a '�
Professions CodeJ: pae5eN7 _
BUILDING � a;i�i(j,�.(��
n, I, as owner of 1he proper�y, or my employees with ADDRE55
� wages as�hair sole compensation,will do the work and �, 5.
the structure is not intended or offered for sale(Section tOCAtiiv � +��!F.�1�.�c�
�n 7044,Business and Professions CodeJ. MOVING TEL
�y� I,as owner of ihe proparty,am exclusively confracting CONTRAQOR NO. , �' l.Q L`�i�
Y-'� wifh licensed controctors lo construcf the project(Sec-
tion 7044,Business and Professions Code). ADORESS
CONSTRUCTION LENDING AGENCY RE4UIRED 70int SeisacK FROM eX15T
SETBACK YARD HWY pROP.LINE WIDThI ,
I hereby affirm thot Ihere is a construction lending agency for FRONT
ihe performance af the work far which ihis permit is issued P.L.
�Sac.3097,Civ.C.). SIDE .
TORONTO ➢OMINION P,ANK P�
m Lender's Name `�y .
$ tender's Address 114 SANSONiE ST. SUITE/70n0� P C.Fea 8 ��i�• 3 Permit Fee T/ -v�
� I cerrify that I ha�a����vn�•slate91l�bMtte Issu ce Fee �� 'S Z
¢ above informafian is corred.I pgree to comply wifh oll CouNy Invesiiqation Fae an
g ordinances and State laws relating to building consiruction, Totnl Fee •��
�i and hereby a�thorize represenfalives of fhis Counfy fo emer
� upon iha obove-mentioned property for inspaction purposes. ��a
� !v� ''�I J�'—V�
n `�_.. .^..�, ,r_ SEE REVERSE FOR EXPLANA70RY LANGUAGE
Signaiure o(ApplicaM or Agan� �ate �s
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