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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 � a ! 1�,,,..,i' A . O d--" . .����,..�'' � .� t � \ 4 �i � �'1 p t� .r-^�� � 'n' U ` 5' (� �,'..��'"'�=c�,U p y O � Q (� � K.,B. 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