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Home My WebLink About1537A 2930A I WORKERS'COMPENSATION DECLARA710N � insure6orafterrntificatelofWorkeneCo1mpens�ilaolns�°a��ego`, APPLICATION FOR .BUJLDING P�ERMIT a cenified copy thereof(Sec.3800,�ab.C.) � GOUN7Y OF LOS ANGELES BUILDING AND SAFfiTY PolicyNo. Company � � Cerrfied copy is hereby furn�shed. FOR APPLICANT TO FILL�N sunow� ��fy ��C � �� ADORF55 � Certified copy is filed with the co�nty building inspeo gUiLDiNG no�dePo��me�r. 'nooeess B7�AZE TRAIL iocnurv �.�c_..�.,t+�.G� .�i'-4.ci NEnREsr Oate Applicam aTY DIA;'ZOND BAR zia CROssST. � -CERTIFICATE OF EXEMPTION FROM WORKERS' � NO OF BLDGS, 1 ASSeS50a COMPENSATION INSURANCE SIZE OF LOT cNOW ON LOT MAP BOOK PAGE PARCEI (This sec�ion need nol 6e completed if the permit is for one . USE ZONE n4AP h�r,dred dollars($loo)or less.) TRACT 3��78 giaK �oLNo. 1Jr1 f�_� SocA I4' a- '34�.� � OWNER��,�% NO. — '^?��'�' CONDITIONS Yr 3 Q a �' . I certify that in�he performance of ihe work far which�his � DISTRICT GROUP TYPE FIRE PROCESSED BY permil is issued,I shall not employ any person' any mann • U so os to ecpme s�bject to ihe rker'Co ens tion�a . ADDRE55 ? CONST�� , p arv YORBA I,INDA zia n268b /C� �'� � 1�� .up.�1 0 Dat� �/rL Applicon ` 7 STATISTiCALClA551FlCATION APT. CON�O. � ARCHITECT�pq� TEL u NOTICE TO APPLICANT:'If, aft r moking this ertifica� oF EnlG�nIEERKIri}�RD T`;.4NJ�r+� NO o-660 '� w Ezemption, you should bem sobjec� to �he Workers' q Qn55 No. � � DWELL.uNiTS �'� � Compensation provisions of the bor Code,yoo musf forth- qpORE55�I 291 IRVINE BOULAVARD TUST 5ev�e nv P %. with comply lh such provisions or this permit shall be � — deemed�evoked. coNrencror,OuVNER BUILDER No996-7�+37 gKLy•PG- ' � YALIDATION LICENSED CONTRACTORS DECIARATION t4 �� , . I hereby offirm ihot I am licensed under provisions of Chapter 9 ADDRE55 L (;AJ � NO. VAWAiION . �1 5 3.7 F (commendng with Secrion 7000)of Divis�on 3 of the Bus�ness and yORBA LINDA CA. ��C _� I Professions Code,ond my license is in full torce and effecf. CITY � CLASS $ �r. '�--• �#• • ' •L 3 SIZEFT`�'J/� 5 ORI�ES 'L F MiIOIES 1. CO EK License Number Lic Class - -� •fi 6�.8 0 � DESCRIPTION OF WORK F'S�(['.}.� f� NEW � $�'(''� /"�K' Conrractor �ate ❑ •.e Fj(>F,�Q�; � I om exempf from fhe litensing requirements as I om o A0� � licensed archi�ect or p registered professional anginear ALiER [� FINAL �2,� � �8 G acMng In my prafessionol copacity (Section 7051, REPAIR � DATE Business ond Professions Code), u5E OF oEnnol ❑ F� ' EXISTING 6LOG. Y �� Lic.or Reg.No. Date APPpRINTT�TAI�:IES R.TviCDAN2EL No996-743? � OWNER-BUILDER DECLARATION i hereby offirm thta�I pm exemp�from the CoMrador's License 1 Q4], EICAJON YORBA LINDA,[: Law for ihe following reason (Section 7031.5, Business ond ADDaESS 7 Professions Code): ❑ BUiL�ING • I, as owner of ihe property, pr my employee5 wi�h AqDRESS � waqes os their sole compensation,wi�l do ihe work and . � � - �2�;`.��i �he structure is not intended or oifared for sa�e(Section �OCt+u7v . . � 70d4,Business and Professions Code). MOVING TEI. � #:e + •.e • � I,os owner of the properfy,pm extlusively controcting CONTRACTOR NO. wifh licensed contractors ta consrruct the project(Sec- I L� G.J.O O tion 7044,8usiness and Professions Coda). ADDRE55 REOUIRED TpTAL SEiBACK fROM EXIST o "I,� L,',r!�';�.. CONSTRUCTION LENDING AGENCY SET BACK YARD HWV pROP.LINE WIDTH' � I hereby affirm ihat there is a construction lending oqenty for FRONT ��6,� � —�G �he performance of the work for which this permit is issued p.i. � � (Sec.3097,Civ.C.). SiDE F.L. Lender's Name Lende�s Address RC Fee 5 � �,,;.� Perm��i Fee 7�� - � I certify 1ha1 I have read ihis opplicalion ond state thol the �'C�J,�lr�� Isso e Fee L�•.�J n � above information is mrred.I ogree b camply with o�ll County i„vesr�ga�ion Fee pn� ordinances and State laws relating to 6uilding construction, ; and hereby autharize representolives oF his County to enier Toral Fee �/� -� � u�on the above-mentioned r erty for pection ppurpos s � ,� P t ��--�" SEE REVERSE f-0R EXPLANATORY LANGUAGE ' , Si ture o A I�an1 or A 1 —�� gno pp ic 9en Date O'vL'NER-SUILDER D�CLARATION �,�� PlAtiS TO FFe'UCANT � INS�ECT`QKS NOT� �hereby affirm Ihat I om exempt from Ihe Conlrotlor'a �Te: Aueurr.ei4 Licanse Law for tha following rea,on. (Sec. 7031.5) � Rppr�ve� � — — B�sinPss and Professioxs Code:Any city or rouxty wbicb Na. Date Nc. Dal`c reyuires a pennit to coxstrnct,alter,i�ov�e,dewsvlisH, __�._..-.-,�_Y�� _ _ — . or repaie any strcscture,prior so its issuance,alao req�irea tGe applicunt for sacb/ur'mit ro file a sigrred sia6emrn2 that he is licensedpuasuanS!o iGeprooisioas of tTie Con- � � r � 1� � trRctor's Licenre I.dm(Chapter 9J(cornmenrirtg witb Srn �a - tinn 7000f of Division 3 oj the Eusiness¢nd Professfona � d r/�r„ � CndeJ or t1¢t Ge is exem¢t tberefronx and the basds,for 15e `r '� �� •E i �'�� alleged exemption.Any violatiox of Section 7031.5 by ,I ..^��__� N�airo`i ` G�i^R_:eiee� I� W ` . t . axy¢pp�licoxsJaraperi»etsrbjxtsiA¢oppdfcantEoacivil � P.p�revela �� br apFrmvsd (� ,`,�1� � y '� pexalty of not more tGss.five/aundred doltars(370f3J.J: � , �.___T . ...�.�,�.�, ._ __z,— I.-.�_..�_,.�:.�1 . i q,�� ; ,M ❑ I,os owner of ihe property,or my employees wifh - I ., i -- _. VJo!cr Certifimte I = woges as their sole campensalion,will do ihe work,and �_ the srructure is nm imended or offered for sals(Sec.764d} Health D�partment Business and Pro,/essions Code:Tbe Cantractor's License �!a 3 �P,2 O,� 4�! y�J�j�/^-+ Law does Qot apply to an owaer ojpr perty wbo bui4Cs fire Department I, � � � _ ar improaes tbereox,and wbo does swcb work bimse f ar througb his own emQloyees,provided that surh im- Groding prox�eenewts are not tntended or ofJered Jor sak. If, � - bowever,abe be�i(d�ng or irr�prousm�xt i,�sold wrabiw airr Geolcgicai yeur of completion, t&e ourner-builder wrtl 6o�oe tbe . burdsw of praoeo'og ibat b�dfd f,a!bwild or improve joi Padwkion Protec�ion ' . . the parjrose af snleJ. (FenceJ(Canopy) ❑ I,ns owner of the property,am ex<(usivedy c�kac- tirtg with licensed coniractors to construct the proje[t(Sec. S�eti�!Inspacticn 7044)Business and Professioxs Cnde:Tbs Contractor's (Conc.){Masonry)(Welding) �— License Lau�does not af+ply tn ars o�oxer of property wfio builds or.imfiroues tbercox,and wbu coniracas for sacG Lof Drainage projects with a contractor(sJ licensed pursuont to tl�s Coxtrxtw's Licenae Lnu�J. Parking ❑ lamex�mp'und�rSsc ,B.&7.C.forthis reason DaSe Own�r Ap�sevels Qatee I::�roasew's S6ynaPure INSPECTOICS NOTES —.I__.-- Location— ' (Setback 8 Vards) '_' ''pTJ„�i-' ' ` Foundotions �.G� Slob ��—fl . �J�W�� Frame c2� a ��C�/ ��, kEnergy Insula5ion �, �r O d _A � Lath/Drywall— _ INeriar �,� -� .��.�,� � Loth—Exterior .� a - � �,� � House Number-- ~ Correct 8 Posted � Final— � Entcr on Fronf - i — � �• �