HomeMy Public PortalAbout9441 1/2 LAS TUNAS DR_Building_2/15/1989_neon sign_illuminated channel letters WORKERS' COMPENSATION DECLARATION A
I heiLby affirm that I have a certificate.of consent to self ® � a ®.''n�
insure, or a certificate of Workers' Compensation Insuran A ' PLICATION I•�I\ ,����, �.f PERMIT .
or a certified copy thereof (Seca 3800 Lob. C.) - a
': 'COUNTY,OPLOS LCIS ANGELES. :' BUILDING AND,SAFETY-
Policy No [ Company
Certified co s hereb furn,shed. $' �d10'` FOR APPLICANT.TO
PY Y TISt�G., 'F ADDRESS f
Certified copy is.filed with,the c my building 'n ec- BUILDING
"tion department. ' ADDRESS (/Q;
Gc,
baie c? O / Applicant CITY ZIP �' LOCALITY
CERTIFICATE-OF EXEMPTI FROM WORKER ' NO. OF BLDGS, NEAREST
T SIZE OF LOT NOW ON LOT CROSS
COMPENSATION INSURANCE
(This section need-not be completed if the permit is for one ASSESSOR
hundred'dollarsl($100)or less.)' TRACT BLOCK LOT NO.„.- ” MAP BOOK-. PAGE PARCEL'.
i
QG Q ,� USE ZONE 'y.;;MAP
I-certify that.in the performance' of the wark..for which;thfs OWN �' ��OS NO. ,NO
permit is.issued, I shall'not employ any person in any manner SPECIAL
so as to:become subject 4o the Workers'Compensotion.Laws. ADDRESS Q C CONDITIONS
/. _
Date" Applicant CITY-' .G.. ZIP; 1 Dot
ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE RO ESSED BY
NOTICE TO.APPLICANT:•If, after making this Certificate of i<
Exer:ption,. you should become subject 'to the Workers'
ENGINEER NO.
Compensation provisions of-the Labor Code, you must forth- ADDRESS
.:
- CO€J57%�r �ZONE
with comply with such provisions or this-permit,shall be -
deemed revoked.`- CONTRACTOR NO /
STATISTICAL CLASSIFICATION - A CONDO
LICENSED CONTRACTORS DECLARATION LI CLASS NO - DWELL. UNITS 1;1
C.
I hereby=affirm that I am licensed under provisions'of Chapter 9 ADDRESS Q SY 'NO./ ' 9
(commencing with Section 7000)of Division,3 of the Business and LtC
Profession's Code, and my license is in„full force and effect. CITY; ' r�NTR' R/iGl CLASS ,nW6-
SEWER"MAP
VALIDATIC
SQ. FT. NO.-DF . NO.,OF CHECK BK.' PG: d
License,Number ic.Class' "L�� SIZE STORIES. FAMILIES ONE-
7
NEO.
0
Contractor - FiO� Date • DESCRIPTION OF WORK mF EW -ice
N
VALUATION
0 ..,
F am exempt under Sec'.” �L C GU17ly
ALTER
'B.BP.C."-for this reason L t. t�TT6 / REPAIR O.
bate: USE'OF
DEMOL' Q
S " -
EXISTING BLDG. Z.
Signature TEL�/�''_ FINAL _
APPLICANT
PRINT ` GCQ O` N
OWNER-BUILDER DECLARATION DATE,
I`hereby affirm thoi'I am exempt from the Contractor's License Y`
Law for the following-'reascn(Section 703i:5*,,Business and :ADDRES ST '-S ,J 'FINAL i
Professions Code): . PRESENT
BY :�
BUILDING - L�
I, as owner of the property pr my employees with ADDRESS +
` wages as their sole compensatioh,,will do the work and ;, v
the'structure is not intended or offered for,sale(Section LOCALITY
7044, Business and Professions Code). MOVING' TEL.
I os-owner of the-'property, am ezcluiivelycontracting
CONTRACTOR NO.'
with`licensed contractors to-construct the'project (Sec
tion 7044 :Business and Professi.ons'Code).. € 4h
ADDRESS"
^' REQUIRED TOTAL SETBACK v f 121
CONSTRUCTION LENDING AGENCY TRACK YARD HWY PROP:.LINE WIDTH;
hereby affirm that there is a,construction lending agency for FRONT. t` i El•€,__
the performance of the work,for which this permit is issued P:L „ (tli �•
:. (Sec. 3097, Civ C:)• SIDE f f3_ 3
Lender's Nam k `g' ..
P.L {
rtG�f '
P.C:.Fee$
: Permit Fee
Tender' A dress . 1 ,
-
L D"Ref # )
o: •1'c .,fy at I have r this application and state'that'the " " Issuance Fee LDMA.P/C#'
�.
a "Je"nfarm,tion i co ect:-i agree to Comply with all County:"• (nvesrigdtion Fee1 _
q rdj nces.and t' aws relating to building construction, Total- LDMA'Permf # : '")z
6 on hereby aut ori a rept ,entativesof this Count en enter +f ra-i"7
the abov_- ntion perty for inspection purposes. w
�. `Ti
SEE REVERSE FOR EXPLANATORY LANGUAGEn. ,
Signotu a of Applicant or Agent Date 7-7