HomeMy WebLinkAbout0314A 0672AW(1RKFRS' COMPFNSATION DECLARATION CARPORT 54
hereby affirm that I hove n certificate of consent to self AP-P-LICATI.ON FOR BUILDING PERMIT
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.80W80-83clIQ13.9 Fidelity & Casu
Certified co is hereby furnished. BUILDING v _ ��
_ copy y FOR APPLICANT TO FILL IN ADDRESS
f Certified copy is filed with the county building
inspec-tion department.
Date10-20-81 Applicant Don A. Mosiman
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 tobecomesubject to the W er ' ompensation Laws.
Date !Q--20— 8 1 APPlico
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become .subject to the Workers'
BUILDING 22832 Drive
ADDRESS 972 Town & Country Oran e
SEWER MAP.
with comply with such provisions or this permir shall be
ADDREss Hilton
Head
VALIDATION
deemed revoked,.
CONTRACTOR Cork Harbour -
NO594-1841
BK, PG,
NEAREST
REPAIR
CITY Diamond. Bar
zIP91765
CROSS Sir
�✓
VALUATION
NO. OF BLDGS.
ASSESSOR
3440 7.9
rj 200
SIZE OF LOT
NOW ON LOT
MAP BOOK
PAGE
PARCEL
TRACT 36346 BLOCK
LOT N
U5W95
NOP
OWNER
TEL.
NO.
i '
SPECIAL
CONDITIONS
ONEK
DISTRICT
GROUP TYPE FIRE
PROCESSED BY
ADDRESS � -
CONST LONE
�
clTv Los Angeles
zip 90010
ARCHITECT OR
TEL
STATISTICAL CLASSIFICATION
APT. CONDO.
ENGINEER PRC. TOUPq
NO. ' -
CLASS NO.
/,-17-" DWELL. UNITS_
Compensation provisions of the Labor Code, you must forth-
ADDRESS 972 Town & Country Oran e
SEWER MAP.
with comply with such provisions or this permir shall be
TEL
VALIDATION
deemed revoked,.
CONTRACTOR Cork Harbour -
NO594-1841
BK, PG,
LICENSED CONTRACTORS DECLARATION
REPAIR
DATE -1 0 a2-
I hereby affirm that I am licensed under provisions of Ch.ple,9
,UC.
ADDRESS 22900 Golden S r
s Dr.
VALUATION
(commencing with Section 7000) of Division 3 of the Business and
ILIC.
3440 7.9
rj 200
Professions Code, and my license is in full force and effect
CITY Diamond B
CLASS
FT
License Number ,�dfllQ Lia Class R_l
SIZES800 SORES
AMIOLIES
ONEK
Contractor f,,k Harh0iir Date1O-201 21
0am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Rosiness 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 (Sedion 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
I hereby affirm that thereis a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name None
DESCRIPTION OF WORK Carport
NEW �
$t
S i
:�. (,i i, L.. {,
ADD
r
f
-
ALTER ❑
FINAL
I /d
• a a w 21
REPAIR
DATE -1 0 a2-
I v_ cn- 6 3 2
USE OF
EXISTING BLDG.
APPLICANT TEL
DEMOL
FINAL
By
.
a o a s
�, ,, 1
(PRINT) NO
{ 0 7 2 ... 8
ADDRESS
® MOVING TEL. ■
L
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply wilt all County
ordinances and State laws relating to building construction,
a hereby duthorize representatives of this County to enter
pan ih a , ve-mentioned property for inspection purposes.
.2t2� 10-20-81
Signature of Applicant or Agent Date
TOTAL SETBACK FROM EXIST. 0 67, 2 N
PROP- I INF WIDTH
1am55.50
Permit Fee 47 .00 a ®� D, 5 C
O G!1 1
.( 1'. 1 7-81
SEE REVERSE FOR EXPLANATORY LANGUAGE
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