HomeMy WebLinkAbout1093A 1094A WORKER$'COMPENSATION DECLARATION e�'?
I here6y affirm thot I hove a certifimte of�o�5e�,�0 5a�f APPLICATION FOR BUILDING PERMIT za
insure,or a certificate of Workers'Compensation Insurance,
or a cerlified copy fhereof($ec.3800,Lab.C.�
61WBRK448�`� HARTFORD GROUP COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. `Company
� Certified copy is hereby furnrshed. FOR APPLICANT TO FILL IN qooREss � �/i. -4h1�+�.r�
r"1 Certified copy is tiled with the couniy bui�ding inspec- BUILDING ?2
��� tiondeparlmenf. ADDRE55 1454 S. VALEVIEW DR. LOCAUTY ✓>•
NEAREST
Da1e Applicant CIT ZIP CR0555T.
CERTI ICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. _ ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if ihe permit is for one USE ZONE MAP
TRACT 42554 BLOCK �oT 6 �,j No.
hundred dollars($100)or Iess.) �
owNeaBRAMALEA LIMITED TE� — 001 �d� SPECIAL a�
N . d CONDITIONS `�
I certify ihat in fhe performance of the work for which this s*�.
permit is issued,I shall nof employ any person in ony ma�ner DISTRICT GROUP TYPE FIRE PROCESSED BY s�
so as to become s�bjec��o ihe Workers'Compensation Laws. P.DDRESS 3151 AIRWAY AVE. SUITE N CON �pwc �
1 b l�3 ;��� �
aTr S ME5A CA. ziP 92626 �
Dote Applicpnt STATISTICALCLRSSIFICATION APT. CO DO.
ARCHITECT OR TEL ]1C} e„3
Nl1TICE TO APPLICANT: If, after making ihis Certificate of ENGINEER ARF�4 BASSENIAN NO. _ CLASS NO. � DWELL UNITS f/ �
�nption, you should become subjed ta ihe Warkers' �,
pensafion provisions of fhe Lahor Code,you must forlh- qDDRE55 3990 WESTERLY PL. ��170 NEirTPORT B SEWER MAP `�
with comply with such provisions or ihis permit shall 6e TEI. �
deemecl�evoked. coNrencroR$�+'i(�I,L�A CALIF NO — ��1 BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARA710N LIC.
I hereby affirm that I am licensed under provisions of Chopter 9 ADDRES }' V N rvo. 409610 yqWATION
(commencing with Section 7000)of Divisiotl 3 of ihe Business and LIC.
Professions Code,and my licerise is in full force and effect. aTv CA 2626 C�nss B $�35 ,
SQ.FT. NO.OF NO.OF CHECK �, I G%'�I'.
License Numher 409610 i;�.��agg B sae 2542 sroeies Z FAMILIES 1 orve
^��� ^ � lL �' i s m • u�
Controctor[l�i4tv� �Pr�..1.� Datelp�l�r_� DESCRIPTIONOF WORK ZS BR NEW � f, L�
� ADO � � s.;.� I.� C
❑I om exempt onder Sec. ' 1'NCE' qLTER � PINAL
B.&P.C.for this reason NEW CONSTRUCTION REPAIR � DATE �1�'�/�(� y ���S ` '� `�
Date: USe OF FINAL ,� / � � .
EXISTING BLDG. � DEMOL � By ����� p�,(;�-g
Signafure_�w.r— � APPLICAN7 TEL.
OWNER-BUItDER DECLARATION aeiNT� BRUCE L. ABBEY NO.
I hereby affirm thm I am ezempt from tha Conir ' � ase r q ►
�aw for the following reason(Section 7031.5, eusineu and .QDDRESS 3151 AIRYyAY AVE. N COSTA D1E , A
Professions Code): N .�.� C�/.U }�
n I, as owner of the property, or my employees with � ADDRESS a e � a n �
� wages as their sole compensation,will do the work and �
the structure is not intended or offered for sale(Section �oCAUTv �
7044,Business and Professions Coda). MOVING • TEL � °`�J�.C C
� I,os owner of the properfy,am exclusively coMracting CONTRAC70R NO. � 6�` ,1.V(;'_
with licensed comrp<tors to constrvct the project(Ser qDDRE55
tion 7044,Business and Professions Code). G
REQUIRED TOTAL SETBACK FROM EXIST. O'T.O Y_`H..
CONSTRUQION LENDING AGENCY SET BACK YARD HWY PROP.LINE wIDTH '
I hereby affirm ihat ihere is a consiruction lending agency for FRONT
the performance of the work for which Ihis permit is issued P.L.
t$ec.3097,Civ.C.). SIDE
— P.L.
Lender's Name TORONTO DOMTNTON RANiZ 'j
s 114 SANSOME ST. SUITE 700 p.0 Fee$ ���a l�j re,m��Fee �s�T�.Cf�
Lender'sAddressRAN RP.ANCTSC(1� ('A. 941(14
> t� ,J-�}
I certify fhaf I have read Ihis application and state that the Issuance Fee
� above information is correct.I agree to comply with all County Imestiga�ion Fee ` y�
g ordinances and State laws relating fo building construclion, Total Fee S9U • U �
� and here6y auihorize represantatives of ihis Cooniy to enier
� upon ihe above-meNioned properfy for inspection purposes. ���'I ,pY/��, •�N _,_,�, ,p/��-F,.
,��r•� U�,-�..7,�- ��v.�
a SEE REVERSE FOR EXPLANATORY LANGUAGE
n Signatore of Applicant or Agent Dme Bi
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