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City of Santa Ana BUILDING PERMIT PROJECT: PERMIT NO. • a a • SUITE M SRAUITENGE JOB TYPE I hereby alhrm under penalty of perryry Mat I am exempt from the contractors' ADDRESS NATURE Iense law for Me folloxeng reason RANGE BUILDING N OF WORK K Section 10N4A,1,as owner of Me property.or my employees with wages as LEGAL NO OF EXISTING then sole compensation,wll do Me work.and Me structure is nat mtended or DESCRIPTON. Lot Block BUILDINGS d USE oRered for sale - - ---_ -- -. • - __--- Sector,T06aB I,as owner of Me pro Tract - ----- TYPE OF _ - -r�CUPANCY perty amettuarvelycontractmqwdn CONSTRUCTION boensed contractors to construct the profea -ASSESSORS TENANT IMPROVEMENT Date: Pvner PARCELIV AND I OR REMODEL AREA .- • . . . OWNER:iiiiiiiiliiiliiiiiiiiillillillillillilI III NEW I ADDL — _ -IN I ADOL - _ -- 1 st FLR SO FT OTHER SO FT I hereby affirm under Penalty of perjury one of the follownng Declarations ADDRESS NEWUR SO NEW GESSO I have and will maintam a Certificate OI Consent to Self Insure for Workers' ADDL 2ntl FUR SO R - - GARAGE SO FT Lompensauon as provided for by Searon 37X of the Labor Code.for the performance of Me work for which tors Permit Is issued ZONING VALUATION Faye and w it maintain Workers Compensation Insurance,as required by PHONE PLANNING DATE Section 37M of to Labor Code for Me pe turmance of the work for which this APPROVAL BY bated is issued My Workers'Compensation Insurance carrier and policy numberare - -- Ca CONTRACTOR: BLOC. ' Carti er _ PLAN CHECKHECK DATE BY ADDRESS PERMIT \t,l DATE Poncy Number ISSUED By v (this 5oldbor,need not be completed it the permit is for One hunt dollars(S100j - or s) IMPROVEMENTS LANDSCAPING REQUIRED REQUIRED I comity that in the performance of the wick for which the permit s issued l ---- - - wall not employ any person in any manner so as to become subs to the Workers I JOB DESCRIPTION. Comp w of Compensation Las California.and agree that it should become subject to the PHONE Workers' mpen non prwrvons of Section 3100 of the La' r Code I snail - - - - - - - - - -- - --- - lonnwrtnn_TnIly� t/p//$h,,oPrwrsmn �A {��.///� /I(�.,- [//{�'/ STATE _ Date I' rT1� I`�p5lrcan� t,ci�• {.'V,/"s / LICENSEN _-_ -_-__ TYPE �� SANTA ANq WARNING Failure to secure Workers Compensation coverage is unlawful and BUSINESS LICENSE shall sub)ect an employer to cnmmal Penalties and mM fines up to one hundred thousanwddollars($1W"),in addition to Me cost of compensation damages as ENGINEER/ARCHITECT: prlded form SealOb 5)OB a Me Labor Code interest.and attorneys fees LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm under penalty of perury Mat I am licensed under prowsrons of Chapter 9(commencing with Section 1000)of Dmsron 3 of Me Business and Professions Code,and m ce n lull force and etlect �. '` - - - - -- -- License Clas ..(( LrcepSe hid PHONE — - - Date �.l 16"1-ntractor /,C-✓`O LICENSEN • • a FEES I hereby alarm under penalty of pequry Mat More is a construction lending agency for Me performance of Me work for which this permit is issued Sec 3097.Cry C I Leni name Lentleh Address APPLICANTS DECLARATION Demolmon Peoods-Asheztos Notification Federal Regulations(Title 40.Pan 8) Mailing Address Public Counter _Requned Letter,of Notn¢atron Citv of Santa Ana cenr at Me federal regulations regarding asbestos removal are not Building Safety Div. M-tt) 2O�)2n Floor Street appbca to leis pro(ea 2nd Pt001 P.O. Box 92 (714) 647-5800 cemly Mat namely wi Mrs a itya and County state ma es a d State [a o^Is Santa Ana. Ca. 9270I Correa I agree ro comply wren all city ana county ordinances and state laws relating ro building construaon.and hereby author a represerJih�es oft c ry Account No 011-01-5911—Permit Validation CS-605 and County to enter upon mentrbne P pe for r barop.qu ''t es` .�r Applicant br agent•g Date -r ' ..j.r Permm«name(,not) /e R L • ih:,Y'fl( 'rlr r,�l+V-`-UU