HomeMy WebLinkAbout4896AWORKERS' COMPENSATION DECLARATION
I 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.
❑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.
Dote Applicant
NOTICE TO APPLICANTS If, after making this Certificate of
Fxemption, 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 llc. Class
Contractor
❑ I am exempt under Sec,
B. &P. C. for this reason _
Date
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 properly, 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 o 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 BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
ADDRESS PLAN 24A
LOCALITY
CITY DIAMOND BAR ZIP
NEAREST
CROSS ST.
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT NOW ON LOT 0
MAP BOOK
PAGE
PARCEL
4,2558 &
USE ZONE
MAP
TRA42556
BLOCK
OT NO.
NO.
i TEL.
OWNER BRAMALEA LIMITED : NQ.850-1001
SPECIAL
CONDITIONS
DISTRICT
GROUP TYPE FIRE PROCESSED BY
ADDRESS STE, G-1
CONST. ZONE
w
CITY COSTA MESA, CA 92626tP
ARCHITECT OR TEL
STATISTICAL CLASSIFICATION APT. CONDO.
ENGINEER fiRAM BASSENIAN NO. 752-1864
CLASS NO.
DWELL. UNITS
_ 7nnn T.me1Pr1n1 V nT T1VT.Tnr1nT nr. A01
CONTRACTOR BRAMALEA CALIF.
NO. 850—ID
BK. PG,
VALIDATION_
i
LIC
ADDRESS -J1 51 AIRWAY_ AVE.-
— NO.VALUATION
CITY COSTA MESA CA
92626
LIC.— 1$
CLASS
�y.� �'
r7 " �
Ll 9. 6
SQ. FT. FJO. OF
NO. OF
SIZE STORIES
FAMILIES
1
DESCRIPTION OF WORK
NE�Q
AD
• +ALFINAL
�t/A
DATE
o '; G',REUSE
OF
EXISTING BLDG.
DE�APPLICANT
FINAL
TEL.y
(PRINTS
NO.
ADDRESS _
MOVING TEL,
CONTRACTOR NO.
ADDRESS
HWY
TOTAL SETBACK FROM
EXIST,
BACKYARD
PROP. LINE
WIDTH
F
/ c' `�
Permit Fee
Issuance Fee
ee
Total Fee
Signature of Applicant or Agent
Dole
SEE REVERSE FOR EXPLANATORY LA URGE
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