HomeMy WebLinkAbout922 SUNSET DR - Building Permits.:.. , .n,��;�.��
� ' , CI�.STA MESA BUILDING-SAFETY DEPARTMENT
�� � P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant [o Fill in Completely — Use Ink Otily
BUILDING /J'� � -_- � _� .
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OWNER
MAIL
CITV
BRANCH
�
ADDHESS
ARCHITECT
ADDRESS
�
CONTRACTOR
A�DRESS
CITV
STATE
LIC. NO.
S12E
OF LOT
TEL.
TEL.
NO.
CITY
LIC. NO.
INO.O LBF�DGS.
NOW ON LOT
Separate permits are required for
. eleMric, plumbing and heating work.
!7
I heraby acknowletlBe that I have read this application ond staro
that tha above intormatlon is correct end agrea to comply wi:h
all laws regulatinB bu7ltling construction, and I sholl not employ
any pa�son in vlolaSiDn ot tho workmen's compensntion laws at
the State ot California.
I hereby certify thai I am properly licenutl as e contrecior unCer
the Stata ot Californla Businass and Professions Cotle, Oivision 3,
Chapter 9, and thot such licenses ere in full foree antl effect, or I
am ezemo< from the orovisions of the State of Calitornia Busin¢ss
antl Protassions Code Division 3, Chapter 9.
SIB�ature of/� �
Permittee � �� r-
�
aia°2iis 5:�oca���
���IL�A��2MIT I A '
A.P. NO.I/�'/ �S�-iC�OiC� PERMIT NO.
APPROVED
USE OF N
BUILDING
VARDSAPPqOVED I YARDSAPPROVED
MAIN BUILDING ACCESSORV BUILDI
(FROM GLSTREET)
D NCE BET. BET. MAIN & �
MAIN BLDGS. ACCESS. BL�GS.
VAR.# DATE
C.U.P.�} qPPROVED
APPR D
a�'t
a'
SQ. FT. �
THE AMOUNTSHOWN UNDER VALUATION IS FOR m �
THE PURPpSE OF 6iABLISHING A PERMIT FEE ONLY: �
VALUATION PERMIT FEE S �O Q
N
m
B � PLAN CHECK § �� �
LL
5 pp TAX a � �
�U
TOTALPAID E � �
. �� ' COSTA MESA BUILDING-SAFETY DEPARTMENT
• P.O. BOX 1200 C05TA MESA, CALIFORNIA 92626
' For Applicant to Fill in Completely — Use Ink Only
BUILDING -�
ADDRESS �
OWNER OR
TENANT �J
MAI LI NC. I
ADDRE55 �
�' �/ TEL... �
GTV / _O�%�>w/!�i ��%� �//�YO. A.�i.
BRANCH
ADORESS
TEL.
ADDRESS
CONTRACTOR
ADDRESS
TEL.
qTY NO.
F STATE CITY
LIC. NO. UC. NO.
� SIZE NO.OF BLDGS.
0. OF lOT �Q x C% NOW ON LOT
a USE OF
^ EXISfING BLDG.
�
FSeparate permlts are required for
q electric, plumbing and heating work:
F VSE OF BUILDING AND �'�'ORK TO BE PERFORMED
Q
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APPLICATION FO�rli�¢FkJA
RECEIVE V PERMIT
SO �
A.P. NO. ' � � �
BUILDING
AODRE55
UNIT OR
SPACE NO.
TR.NO.
NEW AD� ISLTER REPAIR MO
OWNER �^ � /, � , � �
�
PLANNING ACTION
PERMI'� � 3.75 TL+
�� �
N GROUP Yi— Z'
1 q
DATE IO-22r(p
�ATE
�,
� 1 hereby acknowletlpa the< I hava read this application and stata HOLD FOR SPECIAL REQUI �
y� that the above intormatio� is correct and aB�ee io comply with
a all laws raguleting builtling consiruction, antl I shall not amploy
Z any parson in violatlon ot �e workman's compensaHon laws of
W Me Stete ot Celifornle.
3 I hereby cenity that I am P�operly Iicansatl as a conttactor untler SQ. F
ihe Stata of California Bu57ness antl Professions Code, Division 3, THE AMOUNT
Chapter 9, antl that such Ifcenses ere in full force antl eftact, or I THE PUFPOSE <
em ezempt from Me prov(siOns of the State of California Business VALUATION
antl Profassions Cotla, Divi4�on 3, Chaptar .
Si nature of � ��/((( J
Permittee �f%7 � �fay/�V
or fI'
Authorizetl ABent e t O �
o'
S ovo � �- «
VN UNDER VALUAYION IS FOR m
"ABLISHING A PERMR'FEE ONLV: �
PERMIT FEE S � � ,2, � a
m
PLAN CHECK E _� o
LL
TAX 5 �
U
TOTAL PAID S I/ Q �7 �
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F
; COSTA MESA BUILDINGSAFETY DEPARTMENT APPLICATION FOR STRUCTURAL PERMIT ��j
r.utsun i[uu cuaiwmtaw,cHurunrvu+nmm -
RECEIVE,4 Y PERMIT �,_� '
For Applicant [o Fill in Completely — Use Ink Only --�—�� ���1'2'S s
BUILDING � A.P.NO. -�� 1
ADDRESS �KN C�
OUILDING � � �'C� �
OWNER OR � ADDRE55 Z v
TENANT • �
UNIT OR
MAIIING �' SPACE NO.
ADDRE55 TR.NO. LOT BL .
TEL.
CITV G� O.
NEW ADD L ING DEMOLISH
CqNSTRUCTION ��
LENDER �� �^�
./
BRANCH S�
OW NE R G(„ ((,. �
ADDRESS ,I • ALVE �`
ARCHITECT TEL. USE �� ''/(�rIOM, WI{�I $ 7«�'
OR ENGINEER N . /�
ADDflESS ZONE TVP �/ GROUP `� Z
APPROVED � Z
CONTRACTOR BY DATE
ADDRESS
TEL.
CITV NO.
STATE CITV APPROVEDSETBACKS
LIC. NO. � N �� LIC. NO.
SIZE NO.OF BLDGS. (FflOM C/L STREET
OF LOT � � NOW ON LOT ROM T.
USE OF /a
EXI5TING BLDG. �1'V� (�ti S
Separate permits are required for �. si FT.
electric, plumbing and heating work.
REAR FT.
VSE OF BUILD NG Af�VD WORK TO BE PERFORMED PLANNING ACTION
�/i ¢
DATE
� �y �— APPROVED
� APPROV D'
i
I hereby acknowledge that I hava reatl this application and state �
thet the ebove intormation is correct entl a8ree to comply with
ell laws regulating builtling construcilon, antl I shell not employ �
any person in violation of the workman's compensation laws of �
tha State of California. -
O �..s� ��_ n
I hereby certify that I am proDerly licensed as a contrectar under � FT. ✓`�
the State of Celifornia Business antl Professions Cotle, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR a
Chapter 9, and that such licenses ara in full farca antl atfect, or i THE PURP06E OF ESTABLISHING A PERMIT FEE ONLV: �
am ezempt from the provisions of the Stata ot California Business V VATION q
PERMIT FEE S v
anG Profassions Cotle, Division 3, Chapter 9. �
n
$Ignntura ot PLAN CHECK $ �� �
Perm�'ttee _7� � � �� TAX S Q� S'v E
Authorizetl Ageni Date TOTAL PAID E ,�(�
Y�
'
� COSTAMESABUILDINGSAFETYDEPARTMENT APPLICATTONFOII�STTR[�C�I'ii�-�4ILPERMIT2�,•50 TU
r.u.tsVn ��uu cwir�meas�,cwur�nrvis�7mm .
RECEIV BV PERMIT C
For Applicant to Fill in Completely — Use Ink Only .J ��� 9
BUILDING A.P. NO. Z — �,J6 / � �
ADDRESS
BUILDING � �
OWNER OR ADORE55 •
TENANT
UNIT OR
MAILING a � SPACENO.
ADDRESS
TR.NO.� LOT � � � BLK.
TEL.
CITV � NO. �
NEW ADD LTER REPAIR MOVING DEMOLISH
CONSiRUCTION
LENDER
BRANCH
OWNER
ADDHESS VALUE
ARCMITECT TEL. USE E Q O
OF ENGINEER
ADDRESS ZONE TVPE GROUP �
APPROVEO � \
CONTRACTOR '(�p BV DATE
ADDRESS
TEL.
CITV NO.
STATE CITV �}� �J APPROVEDSETBACKS
U0. N0. � LIC. NCIP`,J � (FROM GL STREET)
512E NO. OF BLDGS , .
OF LOT NOW ON LOT ONT FT.
USE OF
EXISTING BLDG. E �Q C
Sepa�ate permits are required for L. SIDE F-r.
electric, plumbing and heating work:
REAR FT.
USE 07 BUILD�NG A D W FK TO BE`PE R D PLANNING ACTION
V
DATE
/1PPROVED
APPROVEDn'. 1/J/C', f l7 � /rJ'/
LUJ�C cwV O� IS
1 hareby ecknow�atlge thai I have raad this aPPlicetion entl state °
�
that iha ebova ��tormatfon Ia corract antl aprea to comply with
ell lawa reBuleti�6 builtlln8 conrtructlon, and 1 s�sll not employ
any parwn tn v�olation of Me workmen's compensation lawa of ;
t�e Sieie of Cel�tornla.
I hereby cerUfy ffiai I am prope�ly Ilcensetl as a contrector under Sn' FT' °
the Stata of Calitornla Buziness antl Professio�s Cotle, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR o
Chapter 9, end thet such licansea ere In full force antl efleet, or I THE PURPOSE OF ESTABLSHING A PERMIT FEE ONLV: �
am axampt frort� tha provislonsof ihaStataof Calitornia Businezs VALUATION
antl Profeasions Cotla, Dlvislon 3, Chapter 9. PERMIT FEE E �
Q e PLAN CHECK 5 �
SIB�etura of � - / D
Parmlttee � $ �y TAX 5 � '
AuffiorizatlAge oaee 2—.17 �c� � TOTALPAID E �`
r
City of Costa Mesa
BuildinB Safety Dapartment
P.O. Box 1200
Costa Mesa, California
. . i,
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CIERTIFICATE 'OF OCCUPANCY (�J�
�..
• •
The Building located at 922 S��ndet Drive - Unit E and IIn.it C
has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto
tor a Group R-� Occupancy.
UseofBuilding 7r+�inc+rial RnilAincr�� ' � �
Legal Description n n lFd9d_��1_��, � -
� (See reverse side' for Metes and Bounds)
Building Permit No ��AQ� Electrical Permit No.c�dS�/dRAf1R Plumbing Permit No. �H��� ��q���•��
� ' 7929U
Number of apartments —n_ and/or guest rooms —�—
iSSUEDTO: ' BuildingOfficial-�.
by .� !��'r/t'.d'�_ ( "•- ��/%/ i�'1^-'
nOli�"DZ R�'AAT victor c:. Ncc��ton - mzecex>r :..ui.�c:izir u�.vi:.::
- Date,Tnlv 14_ 19R1 �
This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT.BE removed except by the
Building Official of the City of Costa�Mesa under Sec. 306 (e) U.B.C. `- � � _
Form BU 34 Rev: 11'/]0 � � �
�
OWNER HORMOZ RAFAAT DATE Z�Z��gl
10B ADDRE55 922 Stmset Drive BUILDING PERMIT N0. 51419
FIRE ZONE VALUE
TVPE GROUi
SUBCONTRACTOR
NOUGH PLUMBING
PROP. $WR. LINE Q NOUSE CON. �
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGN HEnTING ANO �IR CONOIT101
TEMPORARY SERVICE OR POLE
UNOERGROUNO � POWER �
ROUGH WIRING
TRENCHES FOFMS STEEI
FLOOR SVS�' L�=
BONO BEAM � STEEL REINFOR�
SNEATMING
FRAME AND FLRSHING
LATHING — IN � OUT [�
PLASTER, BROWN COAT
STRUCTURAL, FINAL
HERTING, VENT., REFRIG. AN� A.C.
PLUMBING. PINAL RND G/.5 TEST [
EIECTRIC. FINAL
BUILOING, FINAL
��6-/�/ /'>, ! ...,�v
`i.✓.t+< 7o.�sa.��ti�✓
. i7..ii� `,y.!'_ f%/lC/!�t' Ov� `yJc c ,f/�
CC�9N,E U� 704 yiy,�r, /Y.
�i1o/fif Grravii.. G )
� i 9- �'/ ,<�- � . `,,�;, �
�
APPLICATION FOR A BUILDING PERMIT
BUILDING PERMIT NO. Eiecv�w� W
Trac[ Block Lot Permit No. �
BUIItlin9 Plumbing a
Atltlress (/ / Pormit No. �p
Cross �/ / � Ma<haniwl a
Area Street Pormit No.
m
Owner Typa ol Pro7ect: ❑ New ❑ Aller ❑ Atltlitlon #
Atltlrazs (? S4 N3 ❑ Repalr ❑ Convert ❑ Domo ❑ Occupancy Pmt.
CItY e ZIP Phona O_ A.P. $uP. Diil./
Insp. Area
ArcNteGt/ Zone SPI. Pmt. No.
Oesigner lJcenm No.
� Selbacks P/L Frant C/L SL Street WIGth
AECress
artls Le I 9 ear
Clty 21p Phone
ava ro . a 9 . .
En9lneer Licensa No.
`c ark n9 paces equ re rov e ovare
p Addrass
m CIf 2ip ' Phone Struct No. of No. ot
Y Nelghl Storlai Family
� LICENSED CONTRACTOR'S DECLARATION Park Fecs ves Fee
�° � Requlretl No C.T. RecelPt
m 1 hareby atfirm tha[ I am litensed untler provisions ot Chapter 9
(commancing wlth Seciion 7000 of Division 3 of t�e Business antl
« Professions Cotla and y license is in full torce antl fectl. ZON�9 AP�rovatl By: Da[e
?� �icenee Clas Litense N�mbar
T Date � Controctor 5' • Mlsc.
� Atltlress � � v R'oposetl Use
jy CitYend2iP � �� Pnone "1"iSt"3R417
of Structure
N CONSTRUCTI LENDING AGENCY
� 1 hereby attirm tha[ t�ere is a tonitruction lentling aBency for the
a partormance of the wo�k for which Ihis permit is issuetl ($ec. 3097, Occ. Typ< Cotle
' Civ. C.1. Clau Const. Year
C Lentler's Name USE/OCCUPANCV SI2E SQ. FT.
Lender's Adtlress
J OWNER•BUIIDER DECLARATION
r I hereby aHirm that I em examp2 fwm cha Convactor's Licanse Law 1�
A for tha f011Owing raeson:
� ❑ I, as owner ol the property, or my amployoef with we8ea es Neir 2.
sole compemation, will do the work, end tho svuctwa iz not
�L„ intentlaC or offeretl (or cele.
3.
3 ❑ I, as owner oi thn proper[y, am exclusively cOnhectinB w��h
licensed tonVattors to consvuct the projact.
�d., ❑ I om exempt untlar Sac. , B&PC for thia raexon 4�
d
a Dete Owner
E WORKERS' COMPENSATION DECLARATION Total valuatlon
� I hereby e((i.m thet 1 havo e co.titicate of conaenr [o aelt-insu.e, Encroacnment Permlt ReqWretl ❑ ves ❑ No
or a cortificeto of Workarf Compensetion Inauranca, or e cortifietl
Cm �opY �horeoL/n c 1 /+ Gratling Pmt. G�atllOg
y Policy No�N� -'�0 Company U�nTQ. l nM.� ReQuiretl ❑ Ve5 ❑' NO Pmt. No.
�n � Certitiatl copy ia heroby tumishetl. Rough Gratlinq " �
Qa Cor ifiatl c p is filatl with Or nge ount EMA. ^ �
/ ApprOvetl by: Date
Date � - APPlicunt � ` n�-n�-� 3
CERTIFICAT OF EXEMPTION �
FROM WORKERS'CO VENSATIONINSURANCE Z
(This ¢ection neetl not �o completetl if pormit ie for $100 or lessl. �
I �wtity that In tha pe�tOrmanca Ot the work fOr which thia �ermit if Q
issuatl, I shall not emploY any porwn in any menne� w es to beeome ry
subjecc [o che Workars' Componsation Laws ol Californio. PERMIT FEES
Dat Applicant
NOTICE TO APPLICANT: If, after making xhis Cariificate of 5[ruttural S Plan Check 5
EHamption, you should becoma subjeci to tha Wo.kere' Compensation
provistons of the Labor COGe, you must torthwith comply with such Electrifal § SCe<ial E
provlsions or this permit s�all ba tleemetl revoked.
invest.
I CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE p�umbing S
THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO
COMPLV WITH ALL COUNTY ORDINANCES AND STATE LAWS
RELATING TO BUILDING CONSTRVCTION, AND HEREBY AUTH- Mechanlcal E
ORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON
TNE ABOVE MENTIONED PROPERTV FOR INSPECTION PUR- pre-Gratle �
POSES. Inspection s
Signamre of AOP��u�nt or Agent 7re-GraEe Pormit
Date Rec. No. E Iisue s
Print APPlicenYs/A9em's Name
All spacm within this box muri be completed to pracess P�an Issuance
Check BY: APOrovetl:
CMF W30{ti (6W2tl) �OV. 6/tl0
APPLICATION FOR A BUILDING PERMIT
BUILDING PERMIT NO. Eiectr��� m
Tract Block Lat Permit No. �,
BUlltling � � Plumbing . a
Atltl�¢ss s� ��� �� s/ 2 8 � Varmlt No. �
D
Crosi Mec�aniwl C
qr¢a Street T� J J / Pormit No. a
'm
Owner , � rypaof Project: ❑ New Alter ❑ Atltlitlon �
Atltlress ❑ Repal� ❑ Convert ❑ Oe o ❑ Oc<upancy Pmt.
5 p. DiSt./
CIIY ZIP o e A.P. In P. Area
Arthitect/ � Zone 5� Pmt. No.
Designer p itense No.
Atltlress �e% Setbacks P/L Front C/L t. Streot Witlth
�
YarOs Le t g ear
CItY Q / C� u Z�P � or�
ava O. e 9 . •
r Engincer p � License No.
� rk n9 SpaceS equ�retl o e avera
n Aearess �o J S `
m Clt 2ip PhoneJ $t�uct No. of No. of
Y Height Storles Family
� LICENSED CONTRACTOR'S DECLARATION Park Faes ves Fee
� RequlreC No C.T. Recaipt
m I hareby eff(rm t�et I am licensed under provisions ot Chaptar 9
L (commancinp with Saction 7000 of Division 3 of tha Businezs anG Zoning APProveE By: Date
.. Professions Cotle, antl my license is in full force end ettect).
� Llcensa Clas^ Licanse Number
T Dete Cantractor Misc. '
E AtlAress ProposeO Use
of SVucture
jy, City entl Zip Phone
� CONSTRUCTION LENDING AGENCV
d 1 hnraby affirm that rhare is e conatruction landinp agency for the
a pertormance of the work for which this parmit is issued (Sec. 3097, Occ. Type Cotle
' Civ. C.1. Class Const. Vear
y Lantler's Noma USE/OCCUPANCV SI2E S�. FT.
� Lender's AAtlrasc
J OWNER-BUILDER DECLARATION
r I �ereby aHlrm thet I am axempt from ffie Connacmr's Licensa Law 1�
tO for e following rensan:
Q 1, as owner of tho proparty. or my employeas with wa8as es thair 2.
� sole compnnsation, will do the work, entl t�e svucture is not
« intentletl or uiferetl for sola. 3
� ❑ I, as Ownar Of the prOp¢rty, am exclusively conttacting with
litensetl contrettors ta conriruct tha projett.
.,d„ ❑ I am ezampt untlar Sec. , B&PC for this reason 4•
N
a Det .�OWner
E RKERS' COMPENSATION DECI.ARATION 7otal Valuation
� 1 horoby oflirm thae I have e certiticete of conzent ro zelf-insure, EnCroaCbment Farmit Repuiretl ❑ Ves ❑ No
or a certi(icato of Workers' Compensetion Insurance, or a certiTietl
C cOpy MeraOf. GraEing PmL Gratling
8 Policy No Campany Requlretl ❑ Ves ❑ N Pmt. No.
�a ❑ Cartitied copy is hareby turnishetl, Rough Gratling �
Q❑ Certifietl copV is filetl with Orange County, EMA. AODroveE by: Data 10
Da[e Applicant 3
CERTIFICATE OF EXEMPTION
FROM WORKERS COMPENSATIONINSURANCE Z
(Thif section naed not be completetl if permi[ is for $100 ar less). �
1 certify that in the parformenca of Ihe work tor which t�is permit is Q
issueE, I shell not empl<�y any person in any mannor so as to batome �
sub�ect to thx Workars' Compensetion Laws of Califo�nie. PERMIT FEES
Detw APPlicant
NOTICE TO APPLICANT: If, after makinB this Certificate of Structural S Plan Check E
Exomption, yo� shoultl becOma subjac[ to the Workers' Companaotion
provisions of the Lebor Cotle, you must forthwith comply with such Electrical SPecial
provisions or thls permit shull ba deamed r¢voketl. s InvesL S
1 CERTIFV THAT I HAVE READ THIS APPLICATION ANO STATE plumbing E
THAT THE APOVE �NFORMATION IS CORRECT. I AGREE TO
COMPLV WITH ALL COUNTV ORDINANCES AND STATE LAWS
RELATING TO BUILDING CONSTRUCTION, AND HEREBV AUTH- Mechanical S
ORI2E REPRESENTATIVES HIS COUNTV TO ENTER UPON
THE AB VE MENTIONE-' ROPEqTY FOR INSPECTION PUR- pre-Gratla
POSES �C� /iZ 1 � i�soe«io� s
� Pre-Gratle Permlt
tura ot Applica r Agent Oate Rec. No. s Iizue S
Print A plican['s/Agnnt's ame
All spaces within this bo: murt be completed to promsa �an luuance
CheCk BY: Approvetl:
GMY 033S-9b (tlU-'2tl� �BV. b/tlU
APPLICATIDN FOR A BUILDING PERMIT I"'�� � P�iy�a �
9�z s.u,�.,,s�.f DriVer
BUILDING PERMIT NO. Eiectr�ra� o0
Tra<t Block � Lot Permit No. �
Builtlin9 Plumbin9 a
Atleress / Jsr � � O Q Q 7 Permit No. D
OC7 �
Cross Mechaniwl G
Area Strcet / Permit No. a
.9 • ,—,� m
Owner ! Type of Project: �'New ❑ Allar ❑ Atltlltion tt,
(/
AtltlrEss ❑ Repair ❑ Convert ❑ DamO ❑ Octupancy Pmt.
p O Sup. Dist./
CitY Zip 6�6�one � A.P. InSP.Area
Architect/ � Za�e SVI. PmL No.
Desi9ner Llcense No.
Setbacks P/� Front C/L St. Street Witlth
Atltlress �
Vartls Le [ ig ear
CItY / � i�' ZIO Pnone
ave o�. e i9 . .
En9lneer �% � � UcenSe No. � 7 �� --
,C �k ng Spates ¢qu r¢ �ov ¢ OVG/¢
p, AtlCress ��S � �
m Struct No. oi No. of
m City ZIP ��Z one Height Stories Family
� LICENSED CONTRACTOR'S DECLARATION �' Park Fees Yes Fee
� Requiretl No C.T. Receip[
m I hereby eftirm that I am licansetl untlar provisions of Chepter 9
Icomman<ing with Section 7000 of Oivision 3 of tha Business entl
at. Protes,ions Cotle, nntl my license is in tull torce antl atfnctl. Zoning Approve0 BY: Date
2� Licanse Clas Licenx Number
T Date Conttoctar Misc.
� AtltlraSs �opo58tl Uze
of Structure
ji City antl 2ip Phono
N CONSTRUCTION LENDING AGENCV
� I heraby aftirm t�at there ia e conatructian lantling agenry for the
a Occ. TYPe Cotle
performance of the work tor which [his parmit is iseuatl (Sec. 3097, Class ConSL Vear
' Clv. CJ.
y Lender's Nama USE/OCCUPANCV SIZE SU. FT.
C Lentler's Atltlress
J OWNER-BUIIDER DECLARATION
y 1.
I hereby affirm that I em ezampt from the Conttactor's License Law
1O �the tollowing rexaon:
� I, as owner ot tha prOpar[y, or my amplOye¢s with wagas es thair 2.
sOle cOmpensetion, will tlo the work, antl tha struttura is not
�t„ intendatl or otferatl for sale.
� � I, es owner of the proporty, em exclusively con[ractinB '."ith 3'
licensed cOntrectorcto construct tha project.
r ❑ I am exompt untler Sec. B&PC tor this re)aon ^ 4�
N
a Dat�wnar �� ���
E RKERS' COMPENSATIO ECLARA !ON Total Valuatlon
� I heraby aHirm that I M1eve n cerciticete of conunt xo self-insurq Encroachmen[ Pormit Requlretl ❑�'es ❑ No
or a cartifitete of Worken' Compensation Insurance, or a certitieA
C cOpy thereoL Gratlin9 PmL G�atling
r�i Policy No Company Requi�etl ❑ Ve5 ❑ NO Pml. No.
�a ❑ Certifiatl copy is hereby turnishatl.
Rough Gratlin9 �
Q ❑ Certlfted copy is filatl with Orange County, EMA. qpprovetl by: Date �
Dafe Applicant 3
CERTIFICATE OF EXEMP710N
FROM WORKERS'COMPENSATIONINSURANCE Z
(T�is saetion neatl not be completatl if oarmit is tor $100 or lesal. �
I tertity t�et in [he pertormance o1 the work tor which Nis permit is 3
issuetl, 1 shell not amploy any person in eny manner so as [o Oetome A
zubject to the Workers' Compometion �awzof Calitornia. PERMIT FEES
Dat• Applicent
NOTICE TO APPLICANT: It, eftar making this Cortificate of Structural S Ran Check E
Exomption, y0u sho�lA bocome subject t0 [he Workeri Compensation
orovisions of t�e Labor Cotle, you must forthwith comply wi[h such ElectriWl SGetlal
provfsions or thi� permit shall be tleometl revoketl. s InvesL s
I CERTIFY THAT t HAVE READ THIS APPIICATION AND STATE p�umbing S
THAT THE A80VE INFORMATION IS CORRECT. I AGREE TO
COMPIV WITH ALL COUNTV ORDINANCES AND STATE LAWS
RELATING TO BUILDING CONSTRUCTION, AN� HEREBV AUTH- Machanical $
ORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER VPON
THE ABOVE MENTIONED PROP RTV FOR INSPECTION PUR- pre-GraOe
POSES. �' �� �O Inspectlon S
Pre-G�atle Pe�mi[
Si n t e of AppJlcant o� ABe Dato �— qec. No. a Issue E
P„^� PP�ant's/A t' ��r
All s ces within this box must be com leted to proceu P�an Issuance
� P Check BY: APP�oveC:
�mr vaaawo �o�-ea� rav. a�av