HomeMy WebLinkAboutNo Permit Number (2197)WORKERS'COMPENSATION DECLARATION
I hereby offirm thot l hav o a,,f,o,a of o sa,o sa f APPLiCATION FOR BUILDING PERMITinsure,or o tertifi[ate of Workers'Compenstion Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Por,,.n,oWP2312569 co,„„Y Firenan's Ft]i1C1
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Canifiad copy is hereby furnished. FOR APPLICANT TO FILL IN AOORE55 D f k +U '
Ce iified copy is filed wilh the coonty b ilding inspec- BUiIDwG J
fion depar menL AODRESS 1330 S. ReCl Bluff I,drle ipcnurv i
Date Appli[tlnf CITY - H-y+ ZIP cRossSsr. fLJC LO
CERTIfICATE OF EXEMPTION FROM WORKERS' NO.OF BloGS. a55E550R
COMPENSATION INSURANCE SiZE OF O7 NOW ON LOT ——MAP BOOK PAGE DARCEt
This setlion need not be completed if tha permit is for one USE OfiE MAP
hundred dollars(E100)or less.} TRACT 33636-8 gLOCK LOT NO. 7 y No. f.
own,eR'esley of So. Calif.No 540-0500 Qap'd CONDIilONS d
I cerrify that in fhe performonce of ihe work for which this
permit is issVed,I shali not employ any person in any manner
DISTRKT GROUP TYPE FIRE PkOCE55E 6Y (
ADDRES•O. X 2zOO CONS 20NE
so as t bemme subject ro the Workers'Compensation Lnws. n
O
arr r't Beach zia 92663 d
Date Applimnt SIA715TICALCUSSIFICAiION APT. CONDO.VARCHITECTORTELNOTICETOAPPLICAiJT: If, ufter making this Certificate of ENGINEER -e5 .cidI1C 1R C3 r.,o639-2006 NO. d d DWELL.UNI7 dExempion, you should become subject to the Wwkers' y
Compensation provisions of the Labor Code,yo m st forih- qDDRE551.O3H Q]71 AVe. QTdT1CJe SEWFR MAP z
with comply with such provisions or Ihis parmii shatl be
deemed revoked. CONTRACTOR 58fiE 15 OWl'10Y' NO. 6K. PG, VALlDAT10N
UCENSED CONTRACTORS DECtARATtON
I hereby affirm that 4 om licensed under provisians of Chapter 9 ADORE55 rvo.289274 vaw,arron
jmmmencing with Section 7000)of Division 3 of the B siness and
5 O O.00ProfessionsCode,and my license is in futl 4orce and effecl. QTY C1A55
B-1
i
ticense Number 2H9274 lk.C ass B—Z s
eft
sTORs 2 F MIlOtES 1 o
EK '' '
E
COnlroctof Do e
DESCRIPTION OF WORK S 1. fdlCl. C TE NEW
A
1 om ezempt from the icenaing requirements as i am a W dtt. 3 O2r 3Ic1 e
I icensed architec or a registered professionoi engineer. . nUEu f 1NAL . r.
acting in my professionol capocity (Secfion 7051, P],j 77-8 REPAI2
Business and Protessions Code).USE OF FtHAL -- -
EXISTING BLDG. DEMOL
g
li[.or Re .No. Dote APPIICANT - TEL Y
9
OWNER-BUILDER DECLARATtON PRIN1 2I1TIQ'1 n. 5tark No.540-0500 -- it.'
I hereby offirm that I am exempt from the Controdor's License
qpDRE55 460 DI'. N I't B0c1C11 2 t7 Q t`CLowforihefollowingreoson(Section 7031.5, Business ond
Professions Code): PRE E t h 1` 'G
DBUILDING
I, os owner of the praperiy, or my employees with ADORE55 p`}
woges as their sole compensaiion,will do the woik and
t he structure is not inrended or offered for mle(Seaion `T 5 0 p
7044,Business ond Professions Code). MOviNG ie.
I,as owner of Ihe property,am exdusively conlraaing
CONTRACTOR NO.
wiih licensed conlroctors to mnstrucf the project(Seo- AODRE55 j`v[;(1tion7044,8usiness and Professions Code).
REQUIRED TOTAL SETBAIX FROM E%IST.CONSTRUCTION LENDING AGENCV ' SET BACK YARD HWY pROP.LWE WIDTH y'L', ![;;('_
I hereb y alfirm Iha ihere is a mnsiruction lending agency for FRONT
ihe performonce of Ihe work for which this permit is issued P f 4^`_(
Sec.3097,Civ.C.). SiDe
IJrilt2C 'C.c l].fOY7111 B lT11C
v_t
lender"s Nome
1010 N. Main, Santa Ana P.e. 260.40 7ermit Fee 465.00
lendef`s Address
certify ihot I hove read this opplicalion and stale lhat the Issuonce Fee
7•00
Qo6ove i nformotion is correcl.I agree lo comply with all Counry tnvestignfon Feei
ordinances and Slate laws relaling to building mnsiruction, iotal Fee
ond here6y authorize represenlatives of this County ro enter
apon if e ab v -me tione pro r for inspec ion purpo5es.
a 8O SEE REVERSE FOR EXPLANATORY LANGUAGE
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