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� WORKERS'COMPENSATIONDECLARATION � ' �-�_'�. � � �'. ..- �.�. -,� "���� --�
I hereby affirm Ihat I have a certificate of consent to self APPLICAT�ION� F�Q�tt BUILC�If�iG P�ERMIT �
sure,or a certif cofe of Workers'Compensai'�on Insurance,
or o certified cop thereof{Sec.3800,lab.C.) COUNTY OF LOS ANGEIES BWLDING.AND SAFETY
61 W�TX79�93 .
PaQl�rcy No. ompony
Hartford Group . _ ____.. _ ._.--.--.._.__ _. .
Cenified copy rs hereby fumished. FOR APPLICANT TO FILI IN BUILDING /�3 J% �
ADDRESS
� Certified copy is filed with hhe county buildinq insper � ' euuowG � R �
tion deportment. ADDRE55 1183 South Crestbrook Court a
Dote�Applicant - � CI7Y ZIP LOCALI7Y �
- CERTIFICATE OF EXEMPTION FROM WORKERS'c NO.OF 81�G5. NEAREST . ._ .. . . ..,._
COMPENSAYION INSURANCE SIZE OF toT NOW ON LOT CRO55 ST., _
(This seciion need nm be completed if rhe permif is for one TRACi 42568 � �' �ssessoa � .
.hundred dollars($100�or less.) BLOCK LOT NO. 63 ryWp BOOK -PAGE PARGEL
TEL.
I certify ihah in the performance of ihe work for which this � OWNER NO. _ ��/�� NOP '_��t �f�G�-,�jL
�-� �
permi�is issued,i shall no�employ any person in any monner qDDRE55 315 R CANOITIONS �
so as ro become subject to the Workers'Compensalion lows. � �
c�TY Costa Mesa z�P . 2 �
Dote APPlican� ARCHITECi OR 7EL � �
�"ICE i0 APPLICANT: If, offer moking Ihis Cerfificofe of ENGINEER Aram Basseni an NO. ]rj _j DISTRICi GROUP TYGE FIRE PROCESSED BY � •
.nption, yo� sho�ld 6ecome subje<t to the Workers' �i CON� 2 NE �
�ampensdtion provisions of ihe Labar Code,you must forth- ADORE55 C� `✓�'..3 � � 6 �
wiih comply with such provisions or this permit shall be cq
deemed revoked. TE�� STATISTICAL CLASSIfICAT10N APT. CONDO. �
CONTRACTOR NO.
UCENSED CONTRACTORS DECIARATION - i��. anSS ni0. � DWELL UNITS �
I he�eby affirm fhp�I om licensed under pravisions of Chop�er 9 AODRESS NO. QD � SEWER MAP
(commencing wit6 Secfion 70D0)of Division 3 of�he Business and � uC.
Profess"rons Code,ond my Ikense is in full force ond ef£ect GTv COStd Mesa CL455 B VALIDATION
8K. PG.
54.FT. NO.OF NO.OF CHECK
License Num6er_L{p.�§7.g � u�.c�as: g size 4 sroeies 2 Fa.aiues 1 orve ==G 9!'.0 A
� . . o NEW � VAIUA ON _
contra<tor
Brama7 Pa Cal i f oa�e �ESCRIPTION OF WpRK ,.�" 5 �v/ 7� , " 9 8 ���
aoo
�I om exemp�under Sea � . :.G l�4 !
ALTER
B.&P.C.for this raoson REpa�g � S -- , --7"i! �T
=�i_.:1 -
Date� u5E OF �
EX�STlNG BLDG. NOI�e DEMOt ❑ �
/ �/ [;i'. %C-8.,
Sinnori�rr � �G.P�h.- P/�.fw/ APPLICAtJT � � TEL FINAL .
OWNER-BUILDER DECLARATION PRiNt NO. DATE fj%L����
1 hereby afflrm thot I am exempt from the Controctor's License
Law for the following reasd"n(Sec�ion 7031.5, Business and A�oRE55 fINAt
Profe�.sions Code): � " - - - By
�^'^Z BUILDING
I, as owner of fhe properiy, or my emplpyees wiih ADDRESS �(�C)(,,i �
wages as rheir sole wmpensation,will do the wark and ►
ihe strucfure is nof infended or offered for sale(Section �OCALITV � �
7044,Business and Professions Code1. MOVING - - TEL z' 6 �
nI,os owner of ihe properry,am exdusively controcting CONTRACTOR NO. � � �C'G
�p � -i:�L';�i.
with licensed contmctors to conslruci fhe project(Ser qDDRE55
Iion 7044,Business and Professio�s Code�. •, r �`F�;.�v.'�._
CONSTRUCTION LENDING AGENCY REOUIRED yqRD HWV TOTAI,SETBACK FkOM 1 T. . , � � �
SET BACK 7ROP.LINE W7DTH
I hereby affirm that ihere is o construaion lending agency for FRONi -� `�`G J�'.—,}Fi .
the performance o4 the work fo�which this permit is issued P.f.
(Sec 3097,Civ.C.). S��e �
P.l.
lender'sNome Toronto Dominion Bank - - �
144 Sansome St. Suite 700 �,�p.�J S"��. LD''"^Re` �
Lender's Address . ° P.C.Fee S Permit Fee ' ►
I certify that I hove read this oppiicofion ond stote thpi the . •"�,y� /-.��� . �swoMe Fea � !�i a � LDMA P/C k
above informotion is correct.�agree to comply wiih all Coumy Invesngarion Fee
ordinances and State lows reloling ro building construcrion, �U��� _
and hereby authorize representalives of this County to enter To�ol Fee � � LDMA Perm.N
upon the bove-menfioned properry for inspectian purposes. J p,,�_L� � �
�,,�2�'�J,-u �� G�.�i4�I-��' rP�.-q ,
SEE REVERSE FOR EXPLANA70RY LANGUAGE �
Signaf�re of Appliconr or Agenf � Dale � - � ---- - - � � - - �- -- "
' PLANS TO APPLICANT INSYECTOR'S NOTES 014'NSR-BUILDF.R DP_CLARATION
I hereby offirin that I am exempt from ihe Cafitwctor's
To: Refurned - • License Law for ihe following reoson. �Sec 7031.Sj
Approvad Business am.d Prnfessions Code:Axy city or cnunty w5i<b
No. Date No. �DaT¢ reyuires a per»art to con.uruct,alter,imJ�rove,demnlisb,
.. . , .,. . ...., __q,.. ....... ... . ... � or rehurr un)'strncture,Areor to its irsuaxce.ulso reqaires
� . tbe�pplicant/ar uch permit to f'!e a signed stafement
� that be rs li<eno'ed pursuant tn ebe yrovisionx r f tTic Cnn-
. - � , traceor's Lacense L¢w(G apter 9J(commencing wit!Sec-
� tinn 70001�f��'ision 3 of tbe 8usixrsss und PrrJess
- CodeJ or tbat be is axempt therefrom and the basisJor t6e
� � . alleged exenoption.An}•ainlation rf Seatinn 70315 b��
Required pa�e Received ux��applicant Jar a permi[subjecta�tbe apy7icant to a ciid!
Approvals ar Approved penul[y of nnt murc thun five hundreJ doll¢rs(5500/./:
Yes No [ I,as awner of the 6 ert or m yees with
_ pr p y, y emplo
Water Certifimte , , . _ . .... ._. . '�- � wqges as lheir sole compensolion,will do the work,and
ihe struuure�s not intended or of4ered for sale(Sec.7044)
Heal*h Depanment . . . .- � Bwsiness`and Prqjessions Cnde:The Contracror's I,icense
L�m doe_not apply to ure ouner nJ property ufio bur�
Fire Departmenf _ - nr imprnr��s 76ermn,and u�ba dues sucb uork hinualJ or
� � - tbrou,gh bis n employeev,)rua�ided �hat sucb '-
Giadmg provemnnts are xnt intended nr q[fered for sale
. .,. . � bnmever,ahe 6xdlding or i»:provement is sa/d witbin one
Geolog�ml Y�ur J � rxpfettr�R, tl+e nwnenbuilder u.�ill bax�e N�e
burden nf prnving that be did mot build ar improre for
Pedeslrlan ProtecUon . tbe purpnse oJsaLeJ. �
�Fence)�Canopy) � ��� . . , - ��1� �,asownerof7heproperry,omexclusivelyconfrnc
. ling with licensed mnrroctors 10 consrcuci the proler(Sec,
Special Inspection - 7044j$&sittess and�Pr�Jessinns Cnde: 'Tbe Contraconr's
(Conc)�Mosonryj(Welding) . I irnnse l,au•does not applv tn un omner nJprnperty who
builds or ivroproves tberaon,and u�fio cuntracis for suib
Lot Droinpge .. pr jects u�ith a coatructor/.cJ Jicenaed pureuant to Lhc
Cnntracdor's l.icense Law/.
Parking � - �' " - ��� '�� � ' - ''" � L I om exempt under Sec ,8.&P.C.for this
" - � - . reason .
' . _.._.... . _
' Dafe �Owner
Approvals DoTe Inspector's Signature . : . : - . . INSPECTOR'S NOTES �
LOCP�iOtl-- . ' . .
ise,��k a va�ds� ��
�
Fo��dara�s �s `�
Slob .�J (hLu' c i ..
6 .�-�'r--"�,
Frame ,�7�S' �.. .. .. . . .
Energy Insuloiion �.�y . � . .. . • . . ,. � .
U,
LatWDrywall— . . . ..� . . . .- ,..
��ie�ior .,p-S')
Lath..-Exrerior �..�� . .: . . . ., � .
�✓-2_�-1 �.
_.
Ho�se N�mber-- � . - -
. ..... ._._._ __..._. ... .. , . .
Correct&Pos�ed �'� � -� � ���� "
Final-- . ..._.._ . ,- . .. . . � , .
En! n Front
er�� `— X.c.- . . ' . _ . . . . . ..
I' .G_�`,:; !lr
L'!�/'i%:�c�c- -�i_�c Y�"'(� ' ' . .