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Home My WebLink About7358A 7359AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance; or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company Certified copy is hereby furnis C riif'ed copy is fijed it t e un 1 ildiri 'nspetc- ptio partment. Dote �/ Applicant CE TI CATE OF EXEMPTION FROM RKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one -hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant 'TICE TO APPLICANT: If, after making this Certificate of ,nption, you should become subject to the Workers' Lompensotion provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade, and my license is in full forcdoeffect. License Numb Lic. Class ContraA 09 ate ❑ I am exempt under Sec. B.BP.C. for this reason Date: Signature OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Cade): I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name tender's Address I certify that-t'hove re this application and state that the above in rmotion i agree to comply with all County rdina es nd to law la i to building construction, nd he by out rize repr se tativ sof this County t enter t a ve entione prpperty for inspection pur oses. Signot a cf Ap or Agent Dat i r APPLICATION FOR BUILDING PERMIT n COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT T FILL IN ADDRESS f} ADDRESS J �d ADDRBUILDIL ADDRE -� r CI Zlt' LOCALITY NO. OF BLDGS. NEAREST SIZE OF LOT NOW ON LOT CROSS ST. 42560 f` 46 ASSESSOR TRACT BLOCK Lor NO MAP BOOK PAGE PARCEL TEL Co mmunities5 TEL 00� USEE ZONE MAP y OWNERC21iI. - XP avv-r- NO 7 7 ADDRESS 3187-A Airway Avenuen SPECIAL CONDITIONS CITY Costa Mesa ZIP 92626 ARCHITECT O TEL. I ENGINEER OR Sr Assoc. NO. -- DISTRICT �GROUP YPE CONST. _ l FIRE �QNE PRDCESSED BY ADDRESS 3990 Westerly P1. ;{ 170, N.B. 3 /f✓J Communities, In 1ilEL'. 162- l43700 STATISTICAL CLASSIFICATION APT. ONDO. coNTRAc�&' irw CLASS NO, DWELL. UNITS 3187-A Airway Avenue Llc. 393701 ADDRESS NO. SEWER MAP CITY Costa Mesa CLASS B-1 BK PG VALIDATION SQ. NO. OF 2 NO. OF 1 CHECK SIZEH, STORIES FAMIL[ES ONE VALUATION DESCRIPTION OF WORK NEW ® $ 202, 900. 00 ADD S.F.D. , ALTER REPAIR DEMOL ❑ .. FINAL USE OF EXISTING B APP L. I PR NT 3700 DATE � z3 ✓7 3187-A Airway Avenue, C.M. 92626 ADDRESS FINAL B i BRSENT UILD G ADDRESS LOCALITY MOVING TEL. CONTRACTOR NO, IRED YARD HWY TOTAL SETBACK FROM T. ACK PROP. LINE WIDTHNT kADDRESS LDMA Ref. # '] z e $ `�/�7�)Permit Fee U -f r`sissuance I Fee 0 . t� LDMA P/C #ation Fee Total Fee LDMA Perm. # CI AJ `"% � SEE REVERSE FOR EXPLANATORY LANGUAGE n OWNER-13UILDER DECLARA'T'ION I hereby affirm that I am exempt from the Contractor's o License Law for the following reason. (Sec. 7031.5) 1 Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Con- tractor's License Law (Chapter 9) (commencing with Sec- tion 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)•): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044) Business and Professions Code, The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such provements are not intended or offered for sale.. however, the building or improvement is sold within o,.e year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale). ❑ I, as owner of the property, om exclusively contrac- ting with licensed contractors to construct the project (Sec. 7044) Business and Professions Code: The Contractor's License Law does not apply to an nwner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law). ❑ I am exempt under Sec. , 8.&P.C. for this reason QO}e Owner INSPECTOR'S NOTES PLANS TO APPLICANT INSPECTOR'S NOTES To- Returned Approved 11-,1 2—L 06-ZIO ll iJ / .4,kJ(LG4QT n -r-,– No. Date No. Date Approvals Required Date Received or Approved Yes No Water Certificate Health Department Fire Department Grading Geological Pedestrian Protection (Fence) (Canopy) Special Inspection (Cone.) (Masonry) (Welding) Lot Drainage Parking Approvals Date Inspector's Signature Location— (Setback & Yards) Foundations Slab Frame f1z. Energy Insulation lath/Drywall-- Inter}or 11.1046 Lath—Exterior House Number Correct & Posted final Enter on Front Ill- "_, . OWNER-13UILDER DECLARA'T'ION I hereby affirm that I am exempt from the Contractor's o License Law for the following reason. (Sec. 7031.5) 1 Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Con- tractor's License Law (Chapter 9) (commencing with Sec- tion 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)•): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044) Business and Professions Code, The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such provements are not intended or offered for sale.. however, the building or improvement is sold within o,.e year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale). ❑ I, as owner of the property, om exclusively contrac- ting with licensed contractors to construct the project (Sec. 7044) Business and Professions Code: The Contractor's License Law does not apply to an nwner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law). ❑ I am exempt under Sec. , 8.&P.C. for this reason QO}e Owner INSPECTOR'S NOTES