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HomeMy WebLinkAbout1113A 1114A (5) 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 --- 3 --�--- � T , ---�g— --�--� � ��3 �'+�n s Q T a � � "�o cn O E A 3 o n v' ��° G��G� „ y I � , '�e�� ci ?' `s 3 � s � ? "' �� �- �m. � � � � o o' oia �o a � - '; ro � � ��� � r� i a oa! ,s 5 � � ' � ic � o I � 0 3- i '� �, � ��� m !�� � I o• �- .� � � .� .,� c� � ,u G [f (1 � � . T, C ,y' �0'� O � � � p '>7 (l j J 4 Q fJ i � � � o p 3 Q� ` � C � � f f � O O j V E - � O '.r-, ai � �1 i � �N � i �. 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