HomeMy Public PortalAbout9441 1/2 LAS TUNAS DR_Building_9/26/1988_restaurant - 800 sq 777 77,
WORKERS' COMPENSATION DECLARATION
,I,hereby 6ffirm.thpt I ha•ve,a certificate'of consent to self
nsure``,or a certificate of Workers' Compensation Insurance, A P P L I CATION FOR lJ I L�I N G . PERMIT.
or a,certified copy'thereof (Sec. 3800;'Lab. C.) -
COUNTY OF LOS ANGELES BUILDING AN SAFETY
Policy No. -Company - '
Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
PY y ADDRESS
❑ Certified copy is filed with the countybuilding inspec- BUILDING
tion department. ADDRESS 5 v� i
Date Applicant CITY ���/� � Z^ �/7ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' ')80/ ' �`1j5 NOW NE5 OF ON LOT CROSSBLDGS S
COMPENSATION INSURANCE SIZE OF LOT ST.
(This section need not be completed if the permit is for one ASSESSOR'
hundred dol lars.($100).or.less.) TRACT BLOCK LOT NO. MAP BOOK PAGE' PARCEL
EL.L certify that in ythe performance of the work for which"th'is_ OWNERNO�r
b USE ZO MAP
NO.
permit is issued,'I shall not employ any person in any manner ADDRESSv Z% ` i SPECIAL if
l_
CONDITIONS
so as to become subject to the Workers'Compensation Laws. / C)"�
c� — .�� CITY 4r 4 ��Lt ZIP (, V'
Date Q 'Applicant ARCHITECT OR TEL. �
NOTICE.TO PPLICANT: If; after rra this'Certificate of ENGINEER NO. DISTRICT' O TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers' �. CONST. E U
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION. APT. ONDO. U)deemed:revokedr CONTRACTOR N/� NO. Z
LICENSED CONTRACTORS DECLARATION.. LIC. CLASS NO, DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. mow
(commencing with Section 7000)of Division 3 of the Business-and LIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS VALIDATION
SQ. FT. / NO. OF NO. OE CHECK BK. PG. I
License Number Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF-WORK .QL> 11A17 NEW
Contractor Date - ADD ❑ vv
am exempt under Seca •cam `�/� l ❑ ® ;9 0Z.5,i1 A .
ALTER
B.BP C. for this reasonREPAIR "❑ # ,M 23
Dare: USE OF DEMO, ❑ 'I` '2 8 6 8 8 .
EXISTING BLDG. 0
Signature APPLICANT � TEL. FINAL
9 PRINT ew r�/Z/2/ /C7 .NO.
OWNER-BUILDER DECLARATION �," / DATE, —� O`.? 2.8 6,8'8:5
I hereby affirm"that I am exempt from the Contractor's License ADDRESS /Z///V 4� FIN [i '
Law for the following (Section 7031.5; Business and Q Q 7Q 1�
Professions Code). PRESENT
BY:
❑ BUILDING' # 0'0 0:0 0 1
I, .as owner of the property, or my employees with ADDRESS t
wages as their sole compensation,will,do the work and 1 �7
LOCALITY ® I'°-4 791, 1. J�
the structure,is not intended or offered for sale j5ectior= .. .1
44; Business and Professions Code). -" --- MOVING`. TEL.
/ CONTRACTOR- NO. o 0 4 71.7 5 U;
I, as owner of the property, am exclusively.contracting
with licensed contractors to coristruct the project (Sec ADDRESS
tion 7044, Business.and Professions Code). O 9,2 6;`"8 8
/ . . REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD. HWY- PROP.'LINE WIDTH
hereby affirm that there is o'con truction"lending agency for FRONT
the performance of the work for which this permit is issued P.L. - 0 7 7.3"A
(Sec. 3097,'Civ. C.). - SIDE
yr`,
P.L. H o I0
Lender's Name Ref. #
e
# 23
m P.C. Fee$ Permit Fee ' �/t S LDMA ,I °J.0 5..1 .9.
Lender's Address / 1 °•.° 1 .0 5..1 9
3 - /D S LD P/C# j
g I certify that 1,have read this application and state that the S Issuance Fee O 9,2 6:, .8 8
o above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee ( LDMA Perm. # '
R - and hereby authorize representatives of this County to enter
m upon the above-mentioned property for inspection-,purp ses.
- er.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign of-Applicant or Agent Dot
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