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WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy (hereof (Sh 3800, Lab' C. )
Policy No. Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Dote 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 APPLICANY: 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 shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby offirm 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 tic. Class
—
Contractor Date
I am exempt under Sec.
B.BP.C, for this reason
Date:
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
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 Name
Lender's Address
I certify that I have read this application and state that the
above Information is correct. I agree to comply with all County
ordinances and Stale lows relating to building construction,
and hereby authorize representatives of this County to enter
upon the above -mentioned property for Inspection purposes.
APPLICATION FOR BUILDING PERMIT
IT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL INJOC
UILDING
-_
DDRESS
BUILDING
ADDRESS nr
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CITYDIAMOND BAR ZIP
.
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT 0K
PAGE
PARCEL
42�35
MAP
TRACT BLOCK LOT NO.
NO.
TEL
SPECIAL
LA
OWNER L ,A LIMITED N08ci —
CONDITIONS
ADDRESS 3151 AIRWAY AVE. STE. G-1CONST.
T
GROUP TYPE FIRE PROCESSED BY
ZONE
CITY COSTA MESA, CA zIP g2626AL
ARCHITECT O TEL.INEER
CLASSIFICATION APT. CONDO.
ARAM BASSENIAN N 2-1O.
DWELL. UNITS
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CONTRACTOR BRAMALEA CALIF.
No.850-1001
ADDRESS 3151 AIRWAY AVE.
NO t0g_.Q_
CITY COSTA MESA. CA 262
CLASS B-1
SQ• FT. NO. OF
NO. OF
CHECK
SIZE 2240 STORIES 2
FAMILIES
1
ONE
DESCRIPTION OF WORK
NEW
10
ADD
0
NIA
ALTER
n
'5i
n
REPAIR
USE OF
EXISTING BLDG.
DEMO(
APPLICANT
TEL.
MOVING
Annursa
TEL.
REQUIRED
YARD
HWY
TOTAL SETBACK FROM
EXIST.
SET BACK
PROP. UN
WIDTH
FRONT
P. L.
SIDE
P. L.
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P.C. Fee $' 73
Permit Fee
Issuance Fee
Investigation fee
Total Fee
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BK. PG,
VALUATION
s
FINAL
DATE
FINAL
By
J
0
VALIDATION
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Signature of Applicant or Agent Dole
SEE REVERSE FOR EXPLANATO Y LANGUAGE
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