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
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