HomeMy WebLinkAbout7548AWORKERS' COMPENSATION DECLARATION
I hereby offirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lob. C. )
Policy NOWP2312569Company Firmnan's Fund
11 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 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 sholl be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
jmmmencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
ticense Number 289274 Lic. Class B—1
Confractor $alLler aS OWner Dote
1 am exempt from the licensing requirements as I am a
I leaned architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No. 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-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
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 United California Bank
_ lender`s Address 1010 N. Main, Santa Ana
certify that I have read this application and state that the
aabove i nformotion is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
o and hereby authorize representatives of this County to enter
apon ifhe ab v -me tione pro r for inspection purposes.
< 80
Signature of Apphconl or Agent Date
APPLICATION FOR BUILDING PERMIT Il
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
ADDRESS
o S k D
L U/�
NG
1330 S. Red Bluff bane
LOCALITY
/l
AlSS
.T
Fmwland Helyr+t5 ZIP
CROSS NEAREST7.
fL` L' LO
NO. OF BIDGS.
[ADDRESSP-0.
ASSESSOR
F LOT NOW ON LOT —0—
MA/P�BOOt/OK
PAGE
DARCEL
33636-8 BLOCK LOT NO. 70
US
j(/ y
/' r
NOP D ✓
Presley of So. Calif. nio 540-0500
R
d? ffol
CONDIT'CIALIONS
BOX 2200
DISTRICT
GROUP
�o
TYPE
COP
)Y/
FIRE
20NE
✓y
PROCESSED BY
CITY Newport Beach zip 92663
ARCHITECT OR TEL
Charles Sandburg
STATISTICAL CLASSIFICATION
APT. CONDO.
ENGINEER No639-2006
CLASS NO.
e 0 DWELL. UNIT
�
ADDRESS1038 Chalym Ave. Orange
SEWER MAP
BK. PC,,
VALUATION _
$ _46,.000.00
VALIDATION
TEL
CONTRACTOR $aM as owner NO.
ADDRESS `Ivo.289274
CITY CLASS B-1
SO. FT. N06 OF 2 NO, OF
CHECK
SIZE STORIES FAMILIES l
ONE
_
$
DESCRIPTION OF WORK $ 1. faM. dWell
NEW ®
W att. 3 car garage
ADD ID
ALTER
..
Plan 77—B
REPAIR
DATE
FINAL
-- -.... ..
USE OF
EXISTING BLDG.
DEMOL
B F
_..
APPLICANT - TEL
,PRINT D. stark 540-0500 No.
ADDRESS 4600 Canpm Dr. Newport Beach
4• 2 6 0 t: C
••Ch(1 i('v
PRE
BUILDING
ADDRESS
t C F 2 & C)
LOCALITY
;F 7 5 5 0 A
MOVING TEL.
CONTRACTOR NO.
4 • • • •-•
t• 4 7 P 0 C
C
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST.
WIDTH
FRONT
PL
I cP2-5C
SIDE
P_I
l260.40
465.00
PermtFe
7.00
L
Issuance Fee
lion Fee
0
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
}
d
O
V
�G
O
V
LU
N
z
9-11 -a
m y
�, 3 v.M .Q � y ti • .•Q A, �. O %' m y �'
o o `p [SiE
mmc��om•oa aoVo3d
jo,
d ob o �•&
Q d0. m U o •` m .s a 0. of 3
�Ecnc•B°+• 0 pwnonn
o C •o n c
y
O O bp, OF O •w �' 1 p O y
d O O O 2c l
C N C ►. m P t C n y
o •� y �' ., w° n C o 3 c is
El
NS m� is dy�i �' .'�. O a'N O U •� C•~ ��i.
N •w
3teqa o 1Z,-°e> now o^ aqU
u