HomeMy WebLinkAbout4887AWORKERS' 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 therff of (Sec..'f;�,00, Lab. C.1
Policy No. Company
Certified copy is hereby furnished.
QCertified copy is filed with the county building inspec-
lion department.
Dale Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (LIDO) 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 APPLICANT: 6, 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 affirm that I am licensed under provisions of Chapter 9
(commencing with Section AM) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number Lic. Class
Contractor Date
I am exempt under Sec.
B.BP.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby offirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
1, 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
1 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 State laws 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 �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BuuowG
ADDRESS
BUILDING
ADDRESS PLAN
21A
CITY EI AM
RAR ZIP _
NO. OF BLDGS,
SIZE OF LOT
NOW ON LOT
—42! &
TRACT (►2SSb
BLOCK lOI NO
T II I. —
OWNER BRAMALEA
LIMITED 00.7
ADDRESS 3151
AIRWAY AVE. STE, G-
CITY COSTA MESA,
7IP CA
ARCHITECT % BASSENIAN NO. ENGINEER
ADDRESS
LIC.
ADDRESS 3151 AIRWAY AVE. NO
CITY COSTA MESA, CA 92626 CLA
SQ. FT. NO. OF hJ0 OF
SIZE 1430 STORIES 1 IFAMILES1
51N6LE Fr P0_
USE OF
EXISTING BLDG.
APPLICANT
(PRINT)
ADDRESS
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING
CONTRACTOR
ADDRESS
REQUIRED
BACK SETYARD HWY
FRONT
P. L.
SIDE
P.L.
LOCALITY
NEAREST
CROSS ST.
_
ASSESSOR
MAP BOOK
PAGE_ PARCEL
r USE ZONE
�— O1
P
rNO
CIAL
NDITIONS
/
DISTRICT GROUP TYPE
—1864
CONST.
RT Il ,ACf
/O
—1001
STATISTICAL CLASSIFICANON
CLASS NO. DWELL UNITS_
9610
SEWER MAP
B-1
CHECK
BK. PG.
ONE
NEW ®
VALUATION
S
ADD �
ALTER
EPAIR C)
$
DFMOL n
—�
TEL FINAL
NO. DATE
FINAL
By
TEL.
NO.
.I
SETBAC �"
PROP. LItJE WIDTH
P.C. Fee S O r Permit Fee LDMA Ref. N
Issuance Fee LDMA P/C N
Investigation Fee
Total Fee I LDMA Perm. N
APT, I CONDO.
VALIDATION
cL� 8.7A
I 1 6 7
ECEI VE
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�� nr l 3 1984
MECHANJ11A
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SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Data
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