HomeMy WebLinkAbout4895AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I hove a certificate of consent to self
Insure, or o certificate of Workers' Compensation Insurance,
or o certified copy thereof (Sec. 3800, Lob. 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.
Dale i�pplicant
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 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
Controctor Date
I am exempt under Sec.
B.BP.C. for this reason
Date;
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
EJ1, 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 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 slate That the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representalives 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 23C
CITY DIAMOND BAR ZIP LOCALITY
NO. OF BLDGS. NEAREST
SIZE OF LOT NOW ON LOT 0 CROSS ST.
TRT 5 8 & BLOCK LOT NO. ASSESSOR MAP BOOK 1 PAGE PARCEL
OWNER B AMAT, NO. USE ZONE InN,
ADDRESS 3151 AIRWAY AVE. STE , C-1 IAL
DITIONS
cITY COSTA MESA. CA zip 92626
ARCHITECT O TEL.
ENGINEER RAI`t BASSENIAN NO 752-1864
ADDRESS 3990 WESTERLY PL, NEWPORT BEACH
CONTRACTOR BRAMALEA CALIF. No.850-1001
LIC.
ADDRESSAVE, NO. 0 610
CITY COSTA MESAS CA 92626 cicnss B-1
' Q. FT. NO. OF NO. OF CHECK
SIRE 1884 STORIES 2 FAMILIES 1 ONE
DESCRIPTION OF WORK
N/A
(TUG LU F,4kQ L
USE OF
EXISTING BLDG.
APPLICANT
(PRINT)
ADDRESS
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING
CONTRACTOR
ADDRESS
REQUIRED
SET BACK YARD HWY
FRONT
P. L.
SIDE
P.L.
TEL.
TEL.
NO.
Fee $ U6 d Permit Fee
Issuance Fee
stigation Fee
Total Fee
4 /7 7
SEE REVERSE FOR EXPLANATORY LANGUAGE
NEW FL
ADD C
ALTER
REPAIR
DEMOL C
DISTRICT I GROUP I TYPE
CONST
STATISTICAL CLASSIFICATION
CLASS NO. -DWELL. UNITS_
SEWER MAP
BK. PG.
VALUATION
$�_
FINAL
DATE
FINAL
By
:1:
LDMA Ref. N
LDMA P/C N
LDMA Perm. N
FIRE
ZONE
APT. I CONDO.
IN
vau® N.
A
A, • • • • 2
I G. (,16. 7 i
• w'.t',f l
0% G3-8G
Signature of Applicant or Agent
Dale