HomeMy WebLinkAbout4888AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' �-ompensalion Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company
nCertified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date 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 APPLICANT: 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 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 Lic. 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
Law for the following reason (Section 7031.5, Business and
Professions Code):
ElI, 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 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 stale 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.
APPLIC ATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING
_ ADDRESS
BUILDING IIIIII
CITY ll ZIP LOCALITY
NO. OF BLDGS. NEAREST
SIZE OF LOT NOW ON LOT CROSS ST.
2258 & ASSESSOR
TRACT BLOCK JLqT NO. MAP BOOK PAGE PARCEL
OWNERBRAMALEA LIMITED NO 850-1001 USE ZONE MAP
CITY COSTA MESA, CA ZIP 92626
ARCHITECT Qfk , 1M M BASSENIM No752-1.86
ENGINEER Aj�
ADDRESS 3990 WESTERLY PL,NEWPORT BEACH
CONTRACTOR BI AMALEA CALIF'. N�50-1001
ADDRESS 151 AIRWAY AVE No.40 1.
C.
CITY COSTA MESA, CA 92626 CLLASS B-1
SQ. FT. NO, OF NO. OF CHECK
SIZE 1.430 STORIES 1 FAMILIES 1 ONE
DESCRIPTION OF WORK NEW
N/A
USE OF
EXISTING BLDG.
APPLICANT
PRINTI
ADDRESS
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING
CONTRACTOR
ADDRESS
ttttt��r
_
REQUIRED
--SET BACK
YARD
HWY
TOTAL SETP
PROP.
FRONT
P L.
SIDE
P.L.
P.C, Fee $ 3/ Y. / y 15
Permit Fee
Issuance Fee
Investigation Fee
..
Total Fee
TEL.
1141
LINE
ALTER
REPAIR
DEMOL
CONDITIONS r
DISTRICT I GROUP I CONTYPE
ST
STATISTICAL CLASSIFICATION
CLASS NO. ,DWELL. UNITS_
SEWER MAP
BK. PG_
VALUATION
s 6S 6"
s
FINAL
DATE
FINAL
By
LDMA Ref, k
0�_
LDMA PAC M Poo.
LDMA Perm. If
FIRE PROCESSED BY
ZONE
APT. CONDO.
VALIDATION
:488E,A
I.31875
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Signature of Applicant of Agent
SEE REVERSE FOR EXPLANATORY LANGUAGE
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