HomeMy WebLinkAbout4889AWORKERS' COMPENSATION DECLARATION
hereby affirm that I hwe r certificate of, Lionconsent r self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insuran,te, ®��
or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGEIES BUILDING AND SAFETY
Policy No. Company
Certified 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 h r b affirm that I am licensed under rovisions of Cho ter 9
v
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
ADDRESS PLAN 21 C
CITY DIAMOND BAR ZIP
LOCALITY
NO. OF BLDGS.
0
NEAREST
SIZE OF LOT NOW ON LOt
CROSS ST.
42.558 &
ASSESSOR
TRACT 2 BLOCK _ OT NO.
MAP BOOK
PAGE PARCEL
TEI.
USE ZONE
MAP
OWNER NO. —
NO.
ADDRESS 3151 AIRWAY AVE. STE G-1
SPECIAL
CONDITIONS
CITY COgTA MESA, CA zip 92
ARCHITECT OR TEL,
DISTRICT
GROUP TYPE FIRE PROCESSED BY
ENGINEER NO. —
CONST. ZUNE
ADDRESS 3990 WESTERLY PL. NEWPORT BEACH
TEL
CONTRACTOR BRAMALEA CALIF NO.850-1001
STATISTICAL CLASSIFICATION
APT,
CONDO
LIC.
CLASS NO.
DWELL UNITS
ADDRESS 3151 AIRG'A,Y AVF NO G(1
e e Y P P
(commencing with Section 7000) of Division 3 of the Business and
LIC.
SEWER MAP
Professions Code, and my license is in full force and effect.
CITY COSTA MESA CA
92626 CLASSB-1
SQ. FT NO. OF
1
NO, OF CHECK
IFAMILIES 1
BK. PC
License Number tic. Class
SIZ U 3 0 STORIES
ONE
VALUATION
Contractor Date
DESCRIPTION OF WORK
O ADD
D
$ r vC
I am exempt under Sec.
NI A
B.BP.C. for this reason
ALTER n
S/ k)Q-6F REs�� REPAIR 0t
Dole:
USE OF
EXISTING BLDG.
DEMOL ❑
Signature
APPLICANT
TEL,
FINAL
OWNER -BUILDER DECLARATION
PRINT
NO.
DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
ADDRESS
FINAL
Professions Code):
PRrSENT
By
❑BUILDING
I, as owner of the property, or my employees with
ADDRESS
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
LOCALITY
7044, Business and Professions Code).
MOVING
TEL
I, as owner of the properly, am exclusively contracting
CONTRACTOR
NO
with licensed contractors to construct the project (Sec-
lion 7044, Business and Professions Code).
ADDRESS
CONSTRUCTION LENDING AGENCY
REQUIRED YARD HWY
SET BACK
TOTAL SETBACK FROM
PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for
FRONT
the performance of the work for which this permit is issued
P.L.
(Sec. 3097, Civ. C.).
_
SIDE
P.L.
Lender's Name
P.C. Fee 3/fir 7
Permit Fee
LDMA Ref. N
Lender's Address
I certify that I have read this application and slate that the
Issuance Fee
LDMA P/C N
above information is correct. I agree to comply with all County
Invesligation Fee
ordinances and Slate laws relating to building construction,
Toml Fea
LDMA Perm N
and hereby authorize representatives of this County to enter
r
upon the above- me. nt toned properly for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dale
VALIDATION
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