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HomeMy WebLinkAbout1091A 1092A (5) , WORKERS'COMPENSATION DECLARATION � I hereby a���m that I have a certificate of ronsenf to 5e�f APPLICATION FOR BUILDING PERMIT � insure,or a certificote of Workers'Compensation Insuronce, or a cerrfied copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY PolityN6.7LJRRKLG.RIa Compony_HARTFOh'D f;R(1TTP Certified co is he�e6 furnished. BUILDiNG /�7 ❑ PY Y FOR APPLICANT TO FILL IN � Certified copy is filed with�he count buildin ins eo- ADDRE55 ���� �F�C�V'b'-��.t" st i Y 9 P Bl11LDING . !� N tion depariment. ADDRE55 1460 S. VAL�VIEW Dit. �ocnuTr l / NEAREST oare Applicani{��,,..---�, aTr DIAi�? N BAR zivi ceoss sr. CERT ICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE $12E OF LOT NOW ON LOT MAP BOOK PAGE PARCEL I (This section need not 6e completed if ihe permif is for o U NE MAP hundred dollars($100)or less.) TRna 42554 BLOCK �or No. 4 �,�j) No. I TEL. - q� SPECIAL 1 certify ihat in the pertormance of ihe work for which fhis owNeR BIZANtALT9 LIt4ITED NO +��'PC�I�J(7 CON�I710N5 Slh.. DISiRICT GROUP TYPE FIRE PROCESSED BY C� Permit is issued,I shall noi employ any person in any manner r CO ZO 0.d so as to become subjec�to the Workers'Compensmion Ldws. ADDRE5531J1 AIRti']AY AVE. SUITE N i � �-3 '� �' �. � � oare npplicont c��r TA ME A CA. ziP 92626 �S ARCHITECT OR TE STATISTICAL CLASSIFlCATION APT. ONDO. � I ��r.1TICE TO APPLICANT: If, ofler making }his CertiFicpte o4 ENGINEER �'[�$ �NI�] NO. CLASS NO.__t�� DWEIL.UNITS� W7 i �ption, you should become subject to the Workers' - � . pensation provisions af the Labor Cade,you must forth- qDDRE55 ORT B SEWER MAP y '�� with camply with such provisions or ihis permit shall be � • :� �� deemed revoked. lALEA CALIF. rio. 50-1C01 CONTRACTOR BK. PG, VAIIDATION ��, LICENSED CONTRACTORS DECLARATION �IC. , I hereby affirm that I am licensed under provisions of Chapter 9 nooaess3151 AIRWAY AVE. N � No. 409610 VALUATION 'i, (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code,and my license is in full force and effect. C�TvCOSTA MESA �`,Ei. CLASS B 5 l"j,s ��Q , SQ.FT. ND.OF NO.OF CHECK r I Ci�• I A License Number 4n9h1 O Lic.C�a55 R SIZE 2542 STORIEs, FAMIUES 1 ONE �a p p ��.� Contractor RRANi'AT i'A .AT TF pa�e�� DESCRIPTION OF WORK z5 CP. NEW a � j �c 8 1 1 V ❑I am exempt under Sec SINGLE FAMILY RESI➢LNCI: A�� ALTER � FINAL • �J t�. I I :�u B.BP.C.for this reason NEW CONSTRUCTION � �ATE � y L/� � Dote: USE OF REPAIR �'NAL O G(��" ...�.'� EXISTING BLDG. NOIVE DEMOL ❑ BY $ignature • APP�pRNN) BRUCE L. A13BEY No. OWNER-BUILDER DECIARATION - � I hereby affirm that I am exempt from the ConiraUor' en 6 Law for fhe follawing reason(Section 7031.5, Business ond ADD2E55 r_�� C.9`� . Professions Code): PRESENT f""� �BUILDING #,m m p • a '� � I, as owner of ihe properiy, or my employees wifh ADDRE55 ages as their sole compensation,will do the work and I e��1,C r' ihe siruc�ure is not intended or offered for sale(Section �OCAuiv � c-� 7044,Business and Professions Code�. MOVING TEL. �y7 I,os owner af the property,am exdusively controcfing CONTRACTOR NO. ° �"i;��:�,(�(',-s� "� with licensed contractors to construa the project(Seo � r,j C t��` �ion 7044,Business and Professions Code). /+DORESS i""- RE�UIRED TOTAL SETBAIX FROM E%IST. CONSTRUCTION LENDING AGENCY Sei ana YARD HWY pROP.uNE wiDiH ► � I hereby affirm that Ihere is a consiruction lending ogency for FRONT the performonce of the work for which this permit is issued p.�, (Sec.3097,Civ.C.)� SIDE - �enda�s�lame TORONTO DOMINION B[1NK P'� � 114 SANSOY+IE ST. SUITE 70 P.c.Fee$ �8/• f� Pe,m;r Fee �a �•�'� - Lender'sAddres�f{�j �'j��CZSCB� C� ��41.�F � I certify ihat I have read ihis application and state ihat ihe ��• S�� Issuance Fee Q obove informafion is correct.I agree to comply with all County Imestigorion Pee � 5�e�, g ordinances and Sia�e laws reloting to building construcfion, Torol Fea � and hereby authorize represematives of this Coumy to enter � upon ihe above-mentioned property for inspeciion purpo es. � /v �������s �� SEE REYERS�FOR EXPLANA70RY LANGUAGE ^ Signarure af Applicom or Agen1 _ Ome 8s � m_n m —n f{� '^,.i,^��----' ' �'1, fn � T Tf � C`. 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