HomeMy WebLinkAbout4892AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
Insure, or o certificate of-Workers',Compensntion Insurance,
or a certified copy thereof (Sec. 3860, Lob. C. )
Policy No. Company
L_1 Certified copy is hereby furnished.
ElCertified copy is filed with the county building inspec-
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.)
1 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.
Dale _ Applicant
NOTICE. TO APPLICANT:11f, 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
Controctor Date
1 am exempt under Sec.
8.&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):
1, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not iniended 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 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
COUNTY OF LOS ANGELES
BUILDING PERMIT
BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
ADDRESS
—
BUILDING
ADDRESS PLAN 22C
CITY DIAHQIqD BAR ZIP
LOCALITY
NO. OF BLDGS.
SIZE OF LOT 0
NEAREST
NOW ON LOT
CROSS ST.
42558
ASSESSOR
TRACT IL S A BLOCK LOT NO
MAP BOOK
PAGE PARCEL
OWNER 1EL.
B MAT,RA T.TMTTFTI 1V0. R5f1-1 n(Ll
USE ZONE MAP
No
ADDRESS —
SPECIAL
CONDITIONS
CITY ZIP 92
ARCHITECT R TEL.
ENGINEER �12AM BASSE I NO —
DISTRICT GROUP TYPE
FIRE PROCESSED BY
CONST.
CONE
ADDRESS 3990 WESTERLY PL. , NEWPORT BEAC
CONTRACTOR BRAMALEA CALIF. No 850-1001
STATISTICAL CLASSIFICATION
APT. CONDO.
TIC
CLASS NO. —_---DWELL. UNITS
ADDRESS 3151 AIRWAY AVE, NO. 40961
LIC.
SEWER MAP
CITY COATA MESA CA 92626 CLASS B-1
VALIDATION
SQ. FT NO. OF NO OF CHECK
BK PG
— —
SIZE STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK NEW �
$
ADD
ALTER
• • • •
n p y
REPAIR
$
f [I
USE OF
EXISTING BLDG, DEMOL ❑
• . (i I,
APPLICANT TEL
FINAL
PRINT NO,
DATE
U S (I
ADDRESS
FINAL
By
BUILDING
ADDRESS
LOCALITY
MOVING TEL.
CONTRACTOR NO.
SET BACK
YARD HWY
^ rn r.AIJI*
PROP, LINE WIDTH
FRONT
P.L.
SIDE
P.L.
P.C. Fee $
r�
(1�
LDMA Ref. M
Permit
�-�l,;J .
fee
kLD
Issuance Fee P/C $
Investigation
Fee
Total Fee LDMA Perm. #
J ILIA
414s f
SEE REVERSE FOR EXPLANATORY
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Signature of Applicant or Agent Date - (:) I