HomeMy WebLinkAbout4899AWORKERS' 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 tAereof (5+t 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 (f 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
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 Lic. Class
Contractor Date
I am exempt under Sec.
B.BP,C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby offirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
nL._J 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
Lender's Address
I certify that I have 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.
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
ADDRESS PLAN 25A
LOCALITY
NEAREST
CITY
ZIP
CROSS ST.
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT
NOW ON LOT
MAP BOOK
PAGE PARCEL
42 5 yr
USE ZONE
MAP
TRAC tb} 5 6
BLOCK
LOT NO.
NO.
y TEL.
SPECIAL
OWIJF.R
NO. c
CONDITIONS
DISTRICT
GROUP FYPE FIRE PROCESSED BY
ADDRESS �AY AVF
_ • .i —
CONST. ZONE -
CITY COSTA MESA, CA
ZIPS
ARCHITECT OR
TEL
STATISTICAL CLASSIFICATION APT, CONDO.
ENGINEER ARAM BASSF.N
NO. _
CLASS NO.
DWELL. UNITS
�277SZ W ,Q t ,ULI LL. 013 P,
z;cwcn rrvkr
CONTRACTOR BRAMALEA CALIF.
TEL.
No.850-1�01.
BK. PG,
VALIDATION
LIC.
ADDRESS —
NO.
VALUATION
CITY COSTA MESA CA 92626
CLASS B-1
f (j D
p g 9. q p
��N�O,
I
SQ. FT. OF NO, OF
SIZE 2240 ISTORIES 2 FAMIUESI
CHECK
ONE
®
a • • • • � ,?
OF WORK
NEW
fDESCRIPTION
rADDALTER
FINAL
• • LJ J, r
�/A1 �'« ���/ �` g�l
REPAIR
❑
DATE
(I i C 11
USE OF
EXISTING BLDG.
DEMOL
❑
FINAL
Br
APPLICANT
TEL.
MOVING TEL.
CONTRACTOR NO,
ADDRESS
YARD
HWY
TOTAL SETBACK FROM
PROP. LIN
EXIST.
WIDTH
E�ED
5r 3
Permilfee
Issuance Fee
ee
Total Fee
SEE REVERSE FOR EXPLANATORY L LIAGE
10.
I
Signature of Applicant or Agent
Dale