HomeMy WebLinkAbout4890AWORKERS' COMPENSATION DECLARATION
I hereby offirrn that I have a certificate of consent to self
insure, or a certificate of Workers`` Compensation Insuropce,
or a certified copy thereof (Sec. 3800, Lab. C. )
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,
Dole Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensalion 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.&P.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).
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec -
lion 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 Slate 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 BUILDING
ADDRESS
BUILDING
ADDRESS
CITY I)LAMUND fiAf{ ZIP
LOCALITY
NO. OF BLDGS.
0
NEAREST
_
SIZE OF LOT
3255
A)
NOW ON
LOT
CROSS ST.
ASSESSOR
TRACT 5 6
BLOCK
YOT NO.
MAP BOOK
PAGE
L.
OWNER BRAMALEA LIMITED NO.850-1001
USE ZONE
MAP
NO,
ADDRESS 3151 AIRWAY AVE., STE . C-1
SPECIAL
CONDITIONS
CITYCOSTA MESA, CA zip 92626
ARCHITECT OR�M BASSENIAN NO.%52-1864
ENGINEER E11
DISTRICT
GROUP
TYPE
FIRE
CONST,
ZONE
ADDRESS 3990 WESTERLY PL. , NEWPORT BEACH
TEL.
STATISTICAL CLASSIFICATION
CONTRACTOR BRA_MAT.EA CALIF. N(850-1001
3151 AIRWAY AVE. LIC 409610
ADDRESS NO.
CLASS NO.
DWELL, UNITS
SEWER MAP
CITY COSTA MESA CA 92626 CLASS B-1
SQ. FT.
NO. OF
NO, OF
CHECK
BK.
FG.
SIZE
5TORIES
FAMILIES
ONE
NEW
VALUATION
DESCRIPTION OF WORK
$ 7S
Ob0
ADD El
v
NIA
ALTER ❑
/A► ./ n !
_ l VC' LC TA 1 4- 1 f-'c-J I ReI06Q
REPAIR ❑
$
USE Of
EXISTING BLDG
DEMOL ❑
APPLICANT
TEL.
MOVING TEL,
CONTRACTOR NO.
ADDRESS
REQUIRED
YARD
HWY
TOTAL SETBACK FROM
SET BACK
PROP. LINE
FRONT
P. L.
SIDE
PA.
P.C. Fee $ 3,5 - /Zl
Permil Fee
Issuance Fee
Investigalion Fee
Total Fee
of
SEE REVERSE FOR EXPLANATORY LANGUAGE
FINAL
DATE
FINAL
By
/T
LDMA Ref. N
kDNP/C N
LDMA Perm. 0
PARCEL
0.
O
U
49
PROCESSED BY G
Iw
n.
✓1
APT I CONDO, Z
VALIDATION
D1
Signature of Applicant or Agent Date