HomeMy WebLinkAbout4897AWORKERS' COMPENSATION DECLARATION
hereby affirm that I hove 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
ElCertified 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, 1 shall not employ any person in any manner
so as to become subject to the Workers' Compensation laws,
Date Applicant
NOTICE TO APPLICANTS If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must faith -
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 Date
I am exempt under Sec.
B.&P.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 Nome
Lender's Address
I certify that I have read this application and state that the
a' _m 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-menlioned property for inspection purposes.
APPLICATIOIN FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN ADDRE
ADDRESSSS
BUILDING
ADDRESS PLAN 24B
LOCALITY
CITY DIAMOND BAR ZIP
NEAREST
CROSS ST,
NO. OF BLDGS.
SIZE OF LOT 0
ASSESSOR
NOW ON LOT
MAP BOOK
PAGE
PARCEL
&
TRACT 42556BLOCK , LpT NO.
U3E ZONE
MAP
NO.
SPECIAL
OWNER BRAMALEA LIMITED NE0.850-1001
CONDITIONS
DISTRICT
GROUP TYPE FIRE.
PROCESSED BY
ADDRESS 3151 AIRWAY AVE. STE. C-1
CONST. ZONE
CITY COSTA MESA CA zip 92626
ARCHITECT OR TEL.
STATISTICAL CLASSIFICATION
APT. CONK.
ENGINE:EP. No752-1.
CLASS NO.
DWELL. UNITS
ADDRESS 3990 WESTERLY PL. NEWPORT BEACH
SEWER MAI'
CONTRACTOR BRAMALEA CALIF. NO. 850-1001
BK.
PG,
VALIDATION
r, (L 9VALUATION
ADDRESS — NoLIC.09610
CITY QQ51ACA 92626CLASS B-1
$ �
����
t(♦ • • • 2,
Sq. FT. NO. OF NO. OF CHECK
®
I ♦ It It 0
SIZE STORIES FAMILIES 1 ONE
DESCRIPTION OF WORK NEW Fil
ADD 0
N/A
0 IC) '� — � 4
ALTER ❑
FINAL
�-y
REPAIR
DATE
USE OF ❑
EXISTING BLDG. DEMOL
FINAL
APPLICANT TEL
By
PRINT NO.
ADDRESS
11 MOVING TEL.
ADDRESS
YARD
HWY
TOTAL SETBACK FROM
EXIST.
K
PROP. UN
WIDTH
kREQUIRED
/r)G; tf � d `(fD
Permll Fee
Issuance Fee
Investigation Fee
Total Fee
-, / /+ //o
SEE REVERSE FOR EXPLANATORY LA GUAGE
Signature of Applicant of Agent Date
Cs 1