HomeMy WebLinkAbout1095A 1096A (5) WORKERS'COMPENSATION DECLARATION
I hereby affirm thot I have a certifimte of consenf to self APPLICATION FOR BUILDING PERMIT �
insure,or a certifitate of Workers'Compensation Insurance,
or a certified copy thereaf(Sec.3800.Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
PoOli�yrvo.61WBRK448�ompany IIARTFOKD GROUP (
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 \� �`�'�"'
� Certified copy is filed with the counfy building inspec- BUILDING
tian deparfinent. ADDRESS 1450 S. VALEVIEGI DR. iocauTr _/��
NEAREST
�are �applimnt c�TvDIAMOND BAR ziP ceoss sT.
CERTI ICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. _ ASSESSOR
COMPENSATION INSURANCE SitE OF LO7 NOw ON�OT MA7 BOOK PAGE PARCEL
(This seclion need not be completed if the permit is for one US Z MAP
hundred dollars($lOD)or less.) TftACT 42554 BLOCK �OT �t��J tvo,
7E�. SPFCIAL �
I certify Ihat in ihe performance of ihe work for which this OWNER jAj,$[� j,IMiT$D NO$rj�-1�0 ����Y� CONDITIONS
DISTRICT GROUP TYPE FIRE PROCESSED BY w
permit is issued,I shall noi employ any person in any manner AooRess3151 AIRWAY AVE. SUITE N � yj� coNST. z F`�
so as to become subject to ihe Workers'Compensation Laws. d� �� CL
CITY 0 TA MESA. CA. Z�P 9 626 STATISTICAL CLASSIFICATION APT. CONDO. bg
Da1e Applicant ARCHITECT OR 7EL �y� �.d
��7TICE TO APPLICANT: If, afler making this Certificate of [�jj�j $[�SSEIQI� NO, — 864' CtA55 NO. ��� DwELL.uNITS_i..L �'`
ENGINEER �
�nption, you should 6emme subjeti to the Workers' �1,J y
.mpensatian provisions of�he La6or Code,you must forth- qDDee55 WESTERLY PL. STE 170 �c� SEwER n4.4v ',?
with comply "th such provisions or this permit shall be TE� .—
deemed�e�oked. c;oNTencrort BRAr�LEA CALIE�, NO. — ��1 6K. PG, VALIUATION
LICENSED CONTRACTORS DECLARATION uc.
I hereby affirm thot I am licensed under provisions of Chapter 9 ADDRESS O. ]. VALUATION
(commencing with Section 7000)of Division 3 of ihe Business and uC.
Professions Code,and my license is in fuil torce and effect. ciTv COSTA MESA CA.92626 cv+ss B S �Q/ d
SQ.FT. NO.OF NO,OF CHECK
License Number 13(1QF 1Q Lic.Class R 5¢E L STORIES PAMILIES 1 ONE �:�( L�.�%�
Coniractor BRANL4LEA CALIF pa�e� DESCRIPTION OF WORK 23 C NEW � $ �o e A �2�
ADD
❑�am ezempt under Sec. SINGLE FAMILY RESIDEftC� q�TER � FINAL � "`�G�',��
B.&P.C.for�his�eason PIE CONSTRIICTION REPAIR ❑ �AT� r��'���� ��'�r�'1'I '' �
Date:_ USEOF OEMOL FINAI
exisnN�a�o� NOIv� � By u 7,C 2"8�
Signature • APPLICANT TEL —
OWNER-BUILDER DECLARATION PRINT��'R,UCE L. ABBEY NO.
I hereby affirm that I am exerriptfrom the Contractar's '�se Ao�Ress3 51 AIRidAY AVE. N COSTA PSESA.CA. ,
Law for ihe foilowing reason(Section 7031.5, Business and
Professions Codel: PRE EN ;'� O 9 E;�
n BUItDING
� i, as owner of the property, or my employees wiih ADDRESS � � Y
wages as their sole campensation,will do the work and �'`° � �
ihe struct�re is not intended or offered for sale(Section �oCALiTv
7044,Bosiness and Professions Code). MOVING TF�. � �j�l�).�U
LfX'�I I,as owner of Ihe property,am exclusively conirading CONTRAQOR N�� V _ i.
?s with licensed conlractors to construtl 1he projecf(Sec- ADDRE55 � L�`y C�'C U
tion 7044,B�siness and Professions Code).
REOUIRED TOTAL SETBACK FROM EXISL L1 I C G`C��
YARD HWY ►
CONSTRUCTION LENDING AGENCY SET BACK PROP.LINE WIDTH
i here6y affirm ihat there is a consiruction lending agenty for FRONT
ihe performance of the work for which this permit is issued 7.L.
(Sec.3097,Civ.C.). SiDe
Lender's Name
TORONTO DOMINION bANK P'�
S 114 St1i�1SOME ST. SUITE 7OO p.c Fee$ �� � '-EI Parmit Fee �,�.�•�
� Lende�'sAddres��j ��*i�T� ����,_�G.�Qla �
� 1 certify ihat I hove read this application and stote tha�the issu ce Fee C�f`S
� above informa�ion is correct.i ogree to comply with all County Investigotion Fee on ��9 �a
ordinances and State laws relatinq lo building construction, To�al Fee
and hereby authorize representatives of this County to enter
m upon the above-mentioned property for inspection p�rposes.
� �»....._._.r�. C)--Q,-� � ��`7f3 7�<0�' o�-a�,���53`
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