Loading...
HomeMy WebLinkAbout1083A 1084A (5) WORKERS'COMPENSATfON DECLARATION �ry APPLICATION FOR BUILDING PERMIT 1S I here6y affirm that I have a certifimte of mnsen�to self insure,or a certificate of Workers'Compensation Insurance, o�a certified mpy thereof(Sec.3800,Lab.C.) Poi;�YNo.61WBRK448� HARTFORD GROUP COUNTY OF LOS ANGELES BUILDING AND SAFETY ompany � Cer�ified copy is hereby fumished. FOR APPLICANT TO FILL IN auao�rvG nooaess � ���' � � YXI Certified copy is filed with the county building inspec- gUILDING �+ 'LJ fion depariment. ADDRE55 1459 S. VALEVIEW DR. �ocnurv .{�I•�� NEAREST Dote Applicant a..--� CiTY ZIP CROSS ST. ERTI 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 tompleled if ihe permit is for one USE ZONE MAP hundred dolla�s(b100)o�less.) TRACT 42554 g�ocK �or No. 3 �P� No. TE SPECIAL � I certify that in the performance of the work for which ihis OWNE NO.$$�-10�1 �dC�G7 CONDITiONS � ermit is issued,I shall not em lo an �ISTRICT GROUP 7VPE fIRE PROCESSED eV '� p p y y person in any manner AooaEss3151 AI�WAY AVE. SUITE N coNs z� � so as to 6ewme subject to the Workers'Compensalion Laws. �� b^� � arr COSTA MESA CA, zir 92626 1^ � Date Applicant STATISTICALCLASSIFICATION APT. CONDO. 5� MnTICE TO APPLICANT: If, after making this Certificate of ARCHITECTOR TE�. �.L� � �nption, you should 6ecome subject to the Workers' ENGINEER No. 52-1864 C1A55 ND. DWELL.UNITS� � pensation provisions of ihe Labor Code,you must forth- qDORE553990 WEST�RLY PL. If 170 NEWPORT BC sewes nnnP 'R with comply with such provisions or fhis permit shall 6e � deemed revaked. 7EL. gK � VpLI�ATION W' CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION .uC. I here6y offirm that I am licensed under provisions of Chapter9 Ao�aess3151 AIRWAY AVE. ]v ,vo. 409610 yqLUAT10N (commencing with$ection 7000)of Division 3 of ihe Business and LIC. Professions Code,and my license is in full for<e and effed. C�i'('',OSTA A1ESA �,`L�. 92626 CLASS b 5 ��� 409610 B s°EFT 2144 5 ORIOES 2 AMILOIES 1 CO EK , ?, License Number Lic.Class r. � (;��,� Confrocfar 8�11�''�11,E'E1 CL�I.II' pa7q DESCRIP710N OF WORK NEW � � #jo � . .21 ADD ❑I am exempt onder Sea SINGLE PAMILY R�SIDENC� A�TFK � F I N A L �� / � °�4$6 r B.&P.C.forihisreason NEW CONSTRUCTION DATE 4/�'� � REPAIR ❑ � r7�1)Ci = USE OF �� Date: DEMOI ❑ FINAL r EXISTING BLDG. By U I�O C"Y�v Signafure . APPLICAN7 TEL. O NER-BUILDER DECLARATION PRiNT�RUCE i. ABBEY NO. — I hereby affirm ihat I am exempt from�he Contratlor's lic � qDDRE5531 S L AIRCvAY AVE. N COSTA � A. � Law for the following reoson(Seciion 7031.5, Business and a`� C S 4 A Professions Code): PRESENT (', BUILDING ��e e m • e 3 � I, as ownar of ihe property, or my employees with ADORE55 wages as iheir sole compensation,will do ihe work and the strudure is not intended or offered for sale(Sedion LOCALITY i e�E�.(�(� � 7044,Business and Profassions Code). MOVING TEL • I,as owner of Ihe property,am exclusively cantracting C NTRACTOR NO. u ��.�'n`S with licensed contiaaors ro canstruct the project(Sec- tion 7044,Business ond Professions Code). ADDRESS �� ].�)C��y CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETOACK FROM exisi. YAftD HWY , SE7 BACK PROP.uNE WIDTH I hereby affirm that ihere is a construction lending agency for FeoNi the performance of the work for which Ihis permit is issued P.l, (Sec.3097,Civ.C.). SiDE �ender's�vame TORONTO DOMINIOtd BANK P� � 11LF SANSOME ST. SUITE �00 p,C.FeeS ��.3•�%�- Pe�muFee J�77•� Lender's Address i i Sds+-��2uc��EB�E:A;.�rc" 'v^�r I certify that I have read lhis applimtion and state Ihat the Issua ce Fee � r,� Q above information is correct.I agree ro comply with all CouMy Inves�igation Fee n p � ordinances and Stafe laws relating to building mnstruction, Total Fee ��b . aQ ly and hereby authorize represenmfives of ihis County to enter � upon the above-menfioned p�operfy for inspection purpos s. Q g � �U5 �`7/F s S SEE REVERSE FOR EXPLANATORY LANGUAGE ^ Signature ol Applimnt or Agen� Daf �s __... ._--- - -----�-----.._._ � . _�_.. �. �__—�--___.,.�.s..—,._ (' ❑'� o�! ? I o�i C.^ I R, en ; � �,o � � ,� I o ;-au�' I--�,y G� ��� -^ � s i a n WG � � Isl+SI � � � �! � � �0� �c- I � � n � ��o � d �v p �� i�_• 6 � I -�.� T �mc � �D I � o ° o A � � o `•' Q �°`: � �n I �' � s i � � '� + � �� � � n � � o �3 � �o'� Q � ' � !' a � � o� °3 � � � � ro. � '� � � ° a- o -< � � � 'O 3 Q _ �c f I Q � €i � ° 7. � G � � 3 G A � M i � O I 2 � _ � 'O !9 : � ` � °_ � � ��,o '� ro m o 4 _---- -- , -�—�1_..._ m � v� � � ` �� " _ ���� e ��a � Q i � ` i � � ��`��'��� I� : i � �� {� C' � � _— '_ �'__ _.�_ '_"_' �'_ — �___ ' �f—_ � i ��`!,�..�.s---.i �� � ,�- i � � � � -� � ; I �� €''� �., '�: � i ! � i� � _.._..�` '' � --- ---�— � , �---�----�-- . I f � �N � > � � W � � � � � i �' � - q � " � � s � � ! �� i � .� � `.. � a � � j I ` 1 I n � � i I � '_ ° � o � � � i .. �� +� � � � i f�d � ., � m � � i C � " � O � � � I �� � � � i I �- � I $ _—..�.._� �- - - — i ----.— ---- - --� --_ � �..--- —� --�- � _. f ' � �I I I � , ' � : . � � . , . , . j I � � , . � � � � � ; { , , , , ,.. . � _ , , I � I j . , � ' r � I I . I � .� , � I ; � . : � � � � , � � � i � I I — � i 1 � � . � : i ; � � � � , � m j I ; � , . � � - �. � � � � . I : � � m � � 1 , . � � y � � I . E.. - � I : j . � ( I � � i. , � � ` ' � � � ;. ; ; _- I ; ' , . , i ; � � : � ( � , _ � � I , , ; ; ; .. � i ; i I � 1 � : � ; ! I ! i i I i � ' .... � � � I . j , O �� r�b�a;,•F � -• ^. a'1 �.b �. � ''G�s c '7 a ��•.,,.� u�o � � r-_ � � �-' a"� tt. :o �i: r a tl Y `+ � e m ❑ r. � s �; o � X ,� '°.� � n' � � � �p ri � v.::a a� � ��c � � ��� � � 'O _ a �'�C� �# n m � H :� - � r,. ' r, h � ta�� f � w a` s - N �° ` o ��'r •x� ' � �"`� � I _ si n , �_y 4_ ,� w �� �oa � R`4 _ ,v v�`. C �'� n�, ta :� ` <D m I . - t � ` r � '4 ; , `r{ �a � lT'N iC Vi � � .e"Y ea ^t C ^�!�. ;�'i " ! CT _ � �� Q � +�F.' -y p ~� � W n a C � 4 `, N C t1^ n ia t, A r`C p ""!0 C 3^` ,.^, L� 4 I � .. �"`� � � %c p " b w' �� �.�D tC o s h � 2 c�,,�2 m.a, �C °r ° � I � �Y a o � � F y� �^?� C :� � �� m � s '"�.?�� �`�,n. � '�C a 3,7r- �� � ( _ - � � 1 � � � o_� r. � � � ='C�o o m , '4 � �,R,y � � � ( _ i � 'O � , . y �?: iY.Y v ja . - P S ^� .+",,'� uy n. y S r.. P`� 0. `.o `a; � � � ,^y� � � O ]`.Y ..�.�` e. C '^ j'O � i u��c I l � � �"' ;� r`� T " r tu O �'d r�1 n � -t �• (p c y 'G d p .J i..` ,< �" .i �a•'V A O' � S'' `.� �Y � "1� :O �' �` ` I i� YSe ''I`' i � r; �.��.�O � P � w �•'�..Y a d'6 W :t ��K w�:S.` ��C? y 'n O Q ra`•� ��_' + i � ' �' n E cn � : :r.�� ° c'. . �.- � ,� ,� € e � fl-� _° �'� v F`"h �- � o � c � C3 1 + � , �,5 r ��� .V. ro r � a,m ^.r �o u� o �e � �, ° m :: � 1 � :ti I ,I `�k � m "c.,a �, c, c,� � g� ��. e.`�� uYcN: �. m � x � - . E,'e .I a C.w � o c >; .. 1' A'� °o � a"n j'ti.w'.7^: °.A,���p � b �? O ` � � " � � P'.b o .-, Q•a � � ;; c a m� r s � x � � y�c N y � �. -a Ci I ' � � ��. � �,!� S,`a.; � - W.h � � � ,�" � � o �: o � �, '",�� ��'� M m ..,,!.. � I �. I �n f C� '� _y � w.�. ��'�j O�—� 6.A �"S �a' '`° p L°` � p N , � 1 . .. . ' �n y � O � ' 4 ' ' "; = �"' '�ro �.� m � ? a� �"�r' '� �'�:� ��� � a ' � � I I ' 7 ' S'`,�'j-N" J n � � N 0 (G ��^ "a E1'.?3 J��9 �, 't ' T�- I j _ m W '� 'A,� n` � yN � o aL u o ,`e � o �'� a^.x•'��^ N � A �•o U m ' j I � a ,e.e.'r... �y � :='��A. d*'� o � � � � N �'U•T a �^� h m (1� ( 1 I : ;' - , a °.� ''��_` Z..�v ,y ��� � L p�, � ��`'^ o A.= ^ o � �O� M � n C P � �n d W '3 O W.h"� g.� ^t ., �L � I � O ? ti � V Q �1 ',7' 3 uNi �n P :�',n-�w � V K.` f.'`' V a j � � �^ � .� :��.� � � V�� �N �.e s�.. F: .�.�.. J n / � I � ;�n„�•y^• cl fl �.�,v ` w c�i A 9 � �'hct(� n (. � i,u y ""u V O � I 4 I j . t0 . a �'0 Q.T " u�