HomeMy WebLinkAbout1147A 1148A (5)WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to seif "
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No.61WBMX754QQ mpony Hartford' Group
a Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- -
tion department. .
Date 7-74—R7 Applicant_ BraMalPa Calif.
CERTIFICATE OF EXEMPTION FROM WORKERS'
-COMPENSATION INSURANCE . -
(This section need not be completed if the permit is for one
hundred dollars (EI00) 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 Lows. -
Date Applicant
' ?TICE TO APPLICANT: If, after making this Certificaof
mptioten, you should become subject to the Workers'
lompensation 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 409610 Li,. Class B"
Contractor O/B Date
1 am exempt under Sec. -
B.BP.C. for this reason
Signature - - - -- -
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License -
Low for the following reason (Section 7031.5, Business and
Professions Code): " - -
.� I, as owner of the property, or my employees with
J" 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).- - -
1, 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 "Nome - -Toronto Dominion Bank
Lender's Address San Francisco Calif.
1 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 outhorixeNresentatives of this County to enter
upon Iha a v - entparty for inspec ion pui poses.
igna e f Applicont or Agent Do -
APPLICATION FOR BUILDING PERMIT -
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FO APPLICANT,TO FILL IN
BUILDING 24352 East Nan Court
ADDRESS
BUILDING -
ADDRESS 2435' East Nan Court
CITY D.B. Hills ZIP
LOCALITY D.B. Hills
.. - - < .. NO. OF BLDGS _ -
SIZE OF LOT j� NOW ON LOT
NEAREST
CROSS ST.
/
42575 - 28
LESSOR
TRACT BLOCK- LOT NO. f
MAP BOOK PAGE
PARCEL
TEL.
OWNER -- - - O. —
USF�J�Of;
�J)
NOP / . 3 7
ADDRESS 3151 Airway Ave., #N _
opo -v
SPEC AL
CONDITIONS
CITY Costa Mesa zip 92626
ARCHITECT OR TEL.
ENGINEER NO. —
DISTRICT
10
GROUPTYPE
3
CONST.
FIRE
ZON
PROCESSED BY
ADDRESS 3990 Westerly Place #170
TEL -
STATISTICAL CIASSIFICATION"
APT, CONDO.
CONTRACTOR B NO.
..��--��
CU.— NO. DWELL. UNITS
I
LIC. °409610
ADDRESS NO.
LIC
SEWER MAP
CITY/ .- CLASS B
BK. - PG.
VALIDATION
SO. NO. OF NO. OF
CHECK
SIZE — -, STORIES - 2 FAMILIES ' 1
ONE
VALUATION
-
DESCRIPTION OF WORK -
NEW ®
ADD ❑
RETERPAIR
RE ❑
$ oil.1
S IS3 !ii
J ']
- -
1 k7 A
# • • • • 21
.,
SFR
PLAN 25
USE OF -
EXISTING BLDG.
DEMOL ❑
FINALDATE �d����
1 -41323
e.413235
APPLICANTTEL.
PRINT Bramalea Calif. No. 850-1001
ADDRESS 3151Airwav Ave. #N Costa Mesa
FINAL
p $ 2 8 8 7
BUILDING
ADDRESS
, .. ....
LOCALITY ..
MOVING- -... .. - - -. TEL
-... ...'
CONTRACTOR NO.
-
z11tL8A
ADDRESSRQIRE
-
# • • • • 1
) . '7 0 J 0
SETT BACK YARD - HWY . TOTAPROP UNE OM
WIDTH
FRONT
PA,
W
•e705,005
SIDE
LDMA Ref. R
0828-87
L,� /�
Fee S -- T% Permit Fee - s075
10'50LDMA
11c:
.00 Issuance Fee __
P/C Ifestigation
Fee X17
c'�'--'""NS.�
- Total Fee.--
.LDMA. Perm. M- _
SEE REVERSE FOR EXPLANATORY LANGUAGE
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