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WORKERS' 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 (5t c. 3800, Lab.'C. )
Policy No. Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
hundred dollars ($100) or less.)
I certify $hat 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
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation 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 Code, and my license is in full force and effect.
License Number tic. Class
Contractor
I am exempt under Se
B.BP.C, for this reason
Signature
Date
Date:
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 Code):
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 -
lion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby offirm 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
Lender's Address
I certify that I hove read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above -mentioned property for inspection purposes.
� R �e. i. rA' �. a ► � � �e. e
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT 10 FILL IN
BUILDING
ADDRESS
BUILDING
ADDRESS PLAN 25C
LOCALITY
CITY DIAMOND BAR
ZIP
NEAREST
CROSS ST.
SIZE OF LOT
NO. OF BLDGS.
NOW ON LOT 0
ASSESSOR
MAP BOOK
PAGE
PARCEL
TRACT l 5,6 BLOCK
LOT NO.
USE ZONE
MAP
NO.
OWNER
TEL,
NO, —1
1
SPECIAL
CONDITIONS
ADDRESS
TE G-1
DISTRICT
GROUP TYPE
FIRE PROCESSED BY
CONST.
ZONE
ctrYCOSIA MESA ' CA
zip 92626
ARCHITECT OR
TEL
STATISTICAL CLASSIFICATION
APT. CCrNDO.
ENGINEER ARAM $A$SENIAN
No752-1 [
CLASS NO.
DWELL. UNITS
ADDRESS 3990 WESTERLY
_
PL. NEWPORT BEACH
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TOTAL SETBACK FROM
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Permit Fee
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ee
Total Fee
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SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent
Date
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