HomeMy WebLinkAbout4894AWORKERS' 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, lob. C. )
Policy No. Company
(L�J Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
El department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (b100) 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 becorne 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 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 Dote
1 am exempt under Sec.
B.BP.C. for this reason
Dale:
Signature
OWNER -BUILDER DECLARATION
1 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-
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.).
n
Lender's Name
�f
Lender's Address
I certify that I have read this application and state that the
r above information is correct. I agree to comply with all County
ordinances and Slate lows reloling to building construction,
and hereby authorize representatives of this County to enter
g upon the above -mentioned properly for inspection purposes.
APPLICATION FOR BUILDING PERMIT �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING
ADDRESS
BUILDING
ADDRESS
SIZE OF LOT
TRACT 5 8
OWNER R1
LOCALITY
NO. OFNEAREST
NOW OCROSS
ST.
ASSESSOR
ALOTO
MAP BOOKUSE
ZONE
E
&SPE�fDALI
.•ONS
CITY COSTA MESA, CA ZIP 92626
ARCHITECT OR TEL. ffi
ENGINEER ARAM BASSENIAN NO.752-1864
CONTRACTOR BRAMALEA
CALIF.
ivTf350-1001
ADDRESS 3151 AIRWAY
AVE, Now 610
LIC.
CITY COSIA MESA.CA
92 26
CLASS $-1
SQ. FT. INO. OF
NO OF
CHECK
SIZE STORIES
PAMIUES
ONE
DESCRIPTION OF WORK
NEW FL
r
ADD L
N/A
ALTER C
'd kk LF
REPAIR C
USE OF
EXISTING BLDG.
DEMOL
APPLICANT
TEL.
(PRINT)
NO.
SS
LOCALITY
MOVING TEL,
CONTRACTOR NO.
SET BACK I YNRU ! HWY I TOTAPROP. L NESETBACK FROM I WIDT
SIDE
P.L.
P.C. Fee Permit Fee
GROUP I TYPE I FIRE
CONST. ZONE
STATISTICAL CLASSIFICATION
CLASS NO. --DWELL. UNITS
SEWER MAP
BK. PG.
VALUATION
$ D
$
FINAL
DATE
FINAL
By
11
LDMA Ref. R
Invesligotion Fee
Total Fee LDMA Perm M
1J 0y, / 77
SEE REVERSE FOR EXPLANATORY LANGUAGE
11
PARCEL
APT. I CONDO,
VALIDATION
No* a a 2
1 -4067:
• • /1 0 6, l
0 e.Q3-86
Signature of Applicant or Agent Dote