HomeMy WebLinkAbout4893AWORKERS' COMPENSATION DECLARATION
t hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company
❑ Certified copy is hereby furnished.
rj 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 of -firm that 1 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
❑ 1 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):
❑ 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-
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 stole that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby oulhori:e 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 DIAMOND
BAR
ZIP
LOCALITY
NO. OF BLDGS. O
NEAREST
SIZE OF LOT
NOW ON LOT
CROSS ST.
42558 6
ASSESSOR
TRACT
BLOCK
SOT NO.
MAP BOOK
PAGE PARCEL
OWNER BRAMALEA
LIMITED
' TEL.
NO.850-10
USE ZONE
MAP
NO.
SPECIAL
ADDRESS 3151
AIRWAY
AVE • STE-G-
CONDITIONS
CITY '��A•
CA
ZIP92626
ARCHITECT OR
TEL
DISTRICT
GROUP TYPE FIRE PROCESSED BY
ENGINEER
N0. —
CONST. ZONE
ADDRESS 3990
WESTERLY
TEI.
STATISTICAL CLASSIFICATION
APT,
CONDO.
CONTRACTOR B1
LEA
CALIF. N0850=1001
Al
I
LIC.
CLASS NO.
DWELL. UNITS
„ �11 C1
A-rnr.1A'V
ATTV ram. i
ADDRraa _) 1 J 1 L1 L-Lxvy i
Ay J� • V-
CITY COSTA MESA CA
92626
cL,
SQ. FT.
1884
NO. OF
2
NO F
1
SIZE
STORIES
FAMI ES
DESCRIPTION OF WORK
S//JGI FAN1L-Y -C-c
USE OF
EXISTING BLDG.
APPLICANT TEL.
(PRINT) NO.
ADDRESS
SEWER MAP
—1
BK.
VALIDATION
CHECK
ONE
NEW
®
VAL TION
i�� ��.�
:Y'489.3�'t
ADD
❑
ALTER
❑
EPAIR
❑
$
( • A 0 E` 7
DMOL
FINAL
DATE
FINAL
By
LOCALITY
MOVING TEL
CONTRACTOR NO.
ADDRESS
REQUIRED YARD HWY TOTAL SETBACK MOM
',FT RACK PROP. LINE WIDTH
SIDE
P. L.
/ ^� /-LDMA Ref. N
fp � Fee by - Permit fee71Issuance Fee LDMA P/C N
vestigation Fee
r Total Fee J LDMA Perm. N
SEE REVERSE FOR EXPLANATORY LANGUAGE
(P) t
Signature of Applicant or Agent
Dole