HomeMy WebLinkAbout1115A 1116A (5) IWORKERS'COMPENSATION DECLARATION A�i
. Insu�eboraafceriifcar�eof Workesr'Com�peosatanensuran e'f APPLICATION FOR BUILDING PERMIT �
or a certif�ed copy ihereof(Sec.3800,La6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PoliryN�1�u�BRI��+�+S�+Company �RTFORD GROUP
BUILDING
Certified copy is hereby f�rnished. FOR APPLICANT TO FILL IN ADDRE55 1 S�' o C 1'•-'!/4p�++`
� Certified mpy is filed with Ihe county building inspec- eUILDING /�
tion departmenl. ADORE55 LOCALITY �7
NEAREST
� Date� �pplicani -DQ. arv DIAAIOND S zir ceoss sr.
'� RTIF ATE OF EXEMPTION FROM WORKERS � NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZF OF l0T NOW ON lOT MAP 800K PAGE PARCEL
(This section need not be completed if ihe permit is for one � USE ZONE MAP
hundred dollars($100)or less.) TRA� BLOCK LqT NO. NO.
� � T . SPECIAt }
I certify that in the performance of the work for which ihis OWNER., Q_ 1 CONDITIONS `�
permit is issued,I shall not employ any per5on in any monner DISTRICT GROUP TYPE FIRE PROCESSED BY �
so as to become subject to the Workers'Compensation Laws. nooRe553151 AIRWAY AVE. SUITE Td �� cONSi.� ZO �'
�
arv TA MESA CA. z�P 92626 d �' C3
� Date Applicani STATISTICALCLASSIF�CA710N APT. CONDO. �
n�nTICE TO APPLICANT: If, after making ihis Certifimte of ARCHiiECT OR ie�. !��
�mptian, you should become su6jecf to Ihe Workers' ENGINEER - ' i(]N NO. — CLA55 NO. U i! oweu.uN�Ts �
� Ynpensation provisions of�he Lahor Code,you must forth- qooaE553990 WESTERLY PL. ��L�O NEWPORT BC . SEWER MAP i�
, with comply with soch provisions or ihis permit.shall be �
tJeemec�revoked. CONTRACTOR$R(�'jAL�A CALIIP. NO. BK. PG, VALIDATION
� LICENSED CONTRACTORS DECLARATION .LIC.
I here6y affirm ihat l am licensed under provisions of Chapter9 nooaess3151 AIRWAY AVE. N n,o. 409610 VALUATION
(mmmencing with Section 7000)of Division 3 af the Business and uC.
Professions Code,and my license is in full force and effect. CITV ` CLA55 g �.,,,<� �� �
Sq.FT. NO.OF NO.OF CHECK
License Number 409610 �;�.class B size 1430 sroeies 1 FAMuiEs 1 ONE �
DESCRIPTION OF WORK Z1 BR NEW Ll � F I I `v�'
ContracrorBRAM�1LrA CALIP. pQ�e��� ADD
SINGLE FAMILY RESIDENCE � t ` ` ` °�1
❑I am exempt under Sec. ALTER � FINAL �„�� I
B.&P.C.for this reason � DATE �/(� /��r � "� '��
REPAIR
Dote: USE OF fINAL e n%�.`%,�j- '�
/� � � EXISTING BLDG. NONE DEMOL ❑ B - .c. -�
Signafu�e��� -�. ���,-�-� APPLICAMT TEL y c
OWNER-BUILDER DECLARAiION PRINT BRUCE L. ABBEY NO. SO— OOI ��'C l~��"
I hereby aHirm�hat I om ezempt from the Contractor�_ Apoaess3151 AIRWAY AVE. N. CO5TA ►
Law for ihe following reason(Sedion 7031.5,Busine nd
' Professions Code): RE EN
�", BUIl01NG r� � �,6��
� I, as owner of ihe property, or my employees wilh AooRE55 �
wages as their sole compensation,will do ihe work and
ihe siructure is not intended or offered for sale(Section �OCALITY �j a e o m �
�--�y 7044,Business and Professions Code). MOVING TEL.
��/' I,as owner of the properly,am exdusively contracting CONTRACTOR NO. i $��ti��,C��
`�°�' with licensed conrcacrors to mnsiruct�he project(Sec- qooke55 , „�;� r. �. s:
tion 7044,8usiness and Professions Code). "'���"
CONSTRUCTION LENDING AGENCY REqUIRED yqRD HWV TOTAL SETBACK FROM EXIST. � �
$ET BACK PROP.LINE WIDTH , L I�`/�"�F
1 hereby affirm ihat ihere is a construdian lending agency for FRONT
the performance of Ihe work for which this permit is issued P.L.
($ec.3097,Civ.C.�. SIDE
Lender's Name
TORONTO DOMIPIION BAIQK °'�' '
Q 11 SANSOME ST. SUITE p,�,Fee$ �+.s�.�
Lender's AddressSAN FRANCTSCp� ('A_94 �� Pe.m�r Fee �— •�
� I certif tha�I have read�his a lication and state�hat the �� �C�'�
Y PP Issuance Fee
a above information is cwrect.I agree to mmply with all County imesr�gaiian Fee � �1
� ordinances and State laws relating to building construction, ioral Fee v �
and hereby authorize representatives of this County to enter ''
� upon ihe above-mentioned property for inspection purposes. ��. . �� � ��� �
a
SEE ItEVERSE FOR EXPIANATORY LANGUAGE
n Signoture of Applimnl or Agent Dare �s
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