HomeMy Public PortalAbout9441 1/2 - 9445 1/2 LAS TUNAS DR_Building_10/27/1988_Subway - tenant work �'. WORKERS' COMPENSATION`DECLARATION �t � � ✓ KIVO
Her b`affirm that I have a certificate ofconsent to self � �e q
insure or a certificate of Workers' Com ensaiiori Insurance -APPLICATION a �' PERMIT
p C ® ® BUILDING
or a certified copy thereof (Sec: 3800, Lab. C:)- COUNTY OF LOS ANGELES BUILDING AND SAFETY
'Policy,Nom2y�7CompariY, a ifzQ
'Certified copy is hereby.furnished. FOR APPLICANT TO FILL IN BUILDING L /
ADDRESS
j�
Certified'copy is•filed with the county buildin inspec- BUILDING
UU /tion department:' � ADDRESS
57
Date/v / O Applic t CITY EN ZIP LOCALITY
CERTIFICATE OF EXEM TdON FRCIWORKERS' NO.OF BLDG . NEAREST
COMPENSATIONFN CE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one _. ASSESSOR
hundred dollars ($100)or less.) - TRACT BLOCK'' LOT NO. MAP BOOK: PAGE PARCEL
TEL. USE ZONE MAP
I certify that in the performance of the work for which this OWNER � SIV NO. NO. -21
permit is issued, I shall.not employ any person in any manner (/1f SPECIALi
so as'tdbecome subject to the Workers'Compensation Laws. ADDRESS ��`[D •w v CONDITIONS 0
CITY ZIP ✓ fJ
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making.this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY 0
Exemption, you should become.subject ;to the Workers' � I., CONST., ZONE IL
Compensation provisions of the Labor Code, you must forth- ADDRESS - "(4 CL
W
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. J-(;6N5ET_ U)
deemed revoked.
' CONTRACTOR � 5 G t�U NO. —S ., / , . Z
LICENSED CONTRACTORS DECLARATION -4.1�j LIC. CLASS NO. DWELL. UNITS
I hereby-affirm that I am licensed under proJisions'of.Chapter 9 ADDRESS NO. SEWER MAP
(commencing with'Section'7000)of Division 3 of the Business and q/ LIC. 213 5 0-A
.Professions Code, and'my license is in full force and'effect. CITY I3�'{D CLASS BK LPG le�
L9D/'��d,�If T SO. FT. NO. OF NO.OF CHECK JLicense Numbe Lic.Clas "�'V J SIZE. STORIES FAMILIES ONE �. 5O=�� �, �/ NEW. VALUATI N o o vContracto Date DESCRIPTION OF WORK � tsecs :VY . ADD ,;� 211 6 c 8'8
I am exempt under Sec. ALTER
B.BP.C. for this reason soa REPAIR- ❑ $
USE OF1j1���Date: EXISTING BLDG. �JIVDEMOL ClAPPLICANT TEL.Signatur ' • V�� NO. fINAI PRINT)OWNER- UILDER DECLARATION DATE '
I hereby irm that I a exempt from the Contractor's License ADDRESS >� �T7"Ti Vxl�• N� t
Law for the fo eason (Section 7031.5, Business and FI L .1 ;0,1.•�;A'
Professions Code):
BUILDING ,0 2 3
I, as'owner of.the property; or my employees with ADDRESS
wages as their-sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY ® 1 -211 6 7 5
7044, Business avid Professions Code). MOVING TEL.
❑ 1, as owner of the property, am exclusively.contracting
CONTRACTOR NO. ° ° 2 t1 6.7 5
with licensed contractors to construct the project (Sec-
ADDRESS .1..0,2 ]!�8 8
tion 7044, Business and Professions Code). r s• -
REQUIRED
TOTAL SETBAC 4t ;c
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH • - -
i hereby affirm that there is a construction lending agency for _ FRONT. �4 }
.the performance of the work for which this permit is issued P.L.
�Mi s.
(Sec. 3097, Civ. C.). SIDE P.L.
� , �
Lender's Name CDMA Ref # -
m P.C. Fee$ —?,Permit Fee
Lender's Address
1 certify that I have read this application and state that the Issuance Fee (I CDMA P/C#
above information is correct: I agree to comply with all County Investigation,Fee
°o ordinances and State laws relating to building construction, TotaLFee. - ,CDMA Perm. #
6 and hereby authorize representatives of this County to enter
upon the above-me tioned pr perry for inspection urposes.
SEE REVERSE FOR EXPLANATORY,LANGUAGE
—�Sig tura of-Applicant or Agent Date