10117034 - Permit - Laserfiche WebLink

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City of Santa Ana BUILDING PERMIT ADOJ ss: PERMIT NO. • • _ • • SUITEa SUITE JOB TYPE - - RANGE I hereby affirm under Penalty of perjury that I am eaempt from the contractors ADDRESS BUILDING a NATURE license law for the following reason RANGE OF WORK Section➢GaAA.I,as owner of Me properly.or my employees with wages as LEGAL NO OF EXISTING then sole compensation,will do the work.and Me structure is not intended or DESCRIPTION Lot Block BUILDINGS&USE - oflemd for sails - _ - - - _ - -. ` Sect on 1G44B,I,as owner,of Me property iKYconhacting mM CONSTRUCTION GROUP g am eecusl Tract TYPE OF OCCUPANCY )I<ensea consactors to construct the project _ — ASSESSOR'S TENANT IMPROVEMENT .FLOOD Date Owner PARCEL# -- AND I OR REMODEL AREA ZONE - •- • • k • OWNER: . . , _. . NEW I ADOL NEW/ADOL 1st FLR SO FT OTHER SO FT I hereby affirm under Penalty of Perjury one of the fallowing Declarations ADDRESS - NEW I ADDL NEW I ADDL 2nd FLR SO FT GARAGE SO FT I ham and m11 Taman,a Cenihcate Of Consent to See Insure for Workers -- - -- -- - f,ompen ton as pro,ded for by Section 3100 of the Labor Code.for the pedor ce of the work for which this Permit s issued ZONING VALUATION t�and will maintain Workers Compensa!on Insurance.as required by PLANNING _ Sectio,37W of the Labor Code for the performance of the work for which thin PHONE APPROVAL BY DATE permit a issued My Workers Compensat on Insurance err er and policy number -- ---- - are 1{( I CY CONTRACTOR .. . . SLID AI SAFELY �/��v PLAN CHE IL DATE Carnes PObcY Numbel a �/4 I ADDRESS 65R[D B DATE - (this section need not be completed of the permit is for One hundred dollars(S100) - — -- - - -- --- -- or less) - - - - r IMPROVEMENTS LANDSCAPING REQUIRED REQUIRED t certify that n the performance of ,he k f which this permit s issued I - - - -- s all not employ an,person n any man - s 1 P become subject to the Workers _ I HONE JOB DESCRIPTION' Compensation Laws of Cal loin a and ag that if I Should decome subject to the Workers Com bensa on prIt'coulw s race of Se 1 37W of the Labor Code,I shall STATE X O,eformw[ c�mpYPPlcanovsons t TTYPE ,tf--Ty/, LICENSE a A vAl)''��'I / `� W✓✓ri s+i I�"✓ ANTA ANA WARNING Failure to secure Workers Chmpensabon coverage is unlawful and BUSINESS LICENSE a shall subject an employer to criminal penalties and civil does vp to One nundme thousand dollars($100.000),in addition to me cost of compensation,damages as ENGINEER/ARCHITECT: ` l_ provided for in Section 3]O6 of the Labor Code.interest and attorneys lees LICENSED - CONTRACTORS DECLARATION ADDRESS I hereby affirm under penalty of perjury that I am licensed under proasons of Chapter 9(commencing with Section 70X)of Dmsmn 3 of the Business and Prolessions cod a 1 d semis m full tome and effect - -- - - XLicense/Class I'• /y1 W v tiny No Lam.. I PHONE Date It /h Contractor �e LICENSEY — CONSTRUCTION LE • FEES: - I hereby affirm under penalty of is a construction lending agency for Me Performance of the work for which M s permit insured Sec 3091.Cn C) _ Lenders name Lenders Address APPLICANTS DECLARATION Demolition Permits-ASbestos Notihcaron Federal Regulations(Tice 40,Pan 6 Mailing Address Public Counter ) urtetl Leiter of Notification t City of Santa Ana —V/equfy Mat Me federal regulations regamnng asbestos ramwal are not _ _.- - -I Buildins Safety Div. M-19 20G W. dlh. Street apple le to this -._ -.... 2nd Floor p'pj� P.O. Box 1988 cemty that I ham read this application and sate that the adow,information is Santa Ana, Ca. 92701 (714) 647-5800 correct I agree to comply with all City and Count,ordinances and State laws of to building Ponst ct, jj onby inumorae represenathes of mis cnry Account No 011 01-5911 Penh Validation CS-605 and County to enter upon a t beret oned pmpedy for ,sped f es Applicant or agent a g D a �u/V/- ME 4/16/98 8:,9AM -5911 $207.3 0 RSer �%QZiECC t - �� Permmee name lPnnp