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
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