HomeMy Public PortalAbout9445 LAS TUNAS DR_Building_8/29/1988_Lot # 1, 3 pole sign W.., W6,RKERS' COMPENSATION DECLARATIONYaffi�rrt fhat4�-have r certificate of consent to selfAPPLICATION FOR BUI`L®INGPERMITor a certificate of Workers' Compensation Insurance, '
ora certified copy they of (Sec 3800, Lab. C.)
y . . � T/� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poli No. Compar,C�� t =
Certified copy is hereby furnished. . FOR APPLICANT TO FILL IN BUILDING h
ADDRESS 6
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
Dote Applica CITY ) /" ZIP LOCALITY -
CERTIFICATE OF'EXEMPTION FRO RKERS' O. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZ_E.OF LOT OW 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
EL "7OWNER NO. ! �/ USE ZONE MAP /,so—q—
f
I certify that in the performance of the work for which this O. 6� �J
permit is,issued,'.I shall not employ any-person in any manner SPECIALi
ADDRESS//7/19--, CONDITIONS
so as to become subject to the Workers'Compensation Laws. O,
Date Applicant CITY moi/ ZIP '
NOTICE TO APPLICANT:'If, after making this Certificate, of ARCHITECTO p // TEL (%fc DISTRICT GR UP TYPE FIRE ` PROCESSED BY O
ENGINEER /J 1 O h✓ CONST. SONE U
Exemption, you should become subject to. the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS L e _ � 1 - �"' W
with comply with'such provisions or this permit shall be ,y��(� �-
deemed revoked. FEL
a'£� STATISTICAL CLASSIFICATION APT. 150400. N
CONTRACTO - O. `La Z
LICENSED CONTRACTORS DECLARATION > LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions�of Chapter 9 ADDRESS ® NO.
(commencing with Section 7000)of Division 3 of the Business and 4 LIC SEWER MAP
Professions Code,'and my license is in full-force-and effect. CITY Za, " CLASS BK.' PG VALIDATION
��L SQ. FT. NO. OF NO.OF CHECK
License um�e, 156JZ5SIZE'Tlic.Class T STORIES FAMILIES ONE
VALUATION
Contract r rf" DESCRIPTION OF WORK NEW
$
^/
/ �!
❑ I am exempt under Sec. r !� �d ADD' , ;_9
0 4 7,;�.A
�LTER I
# o 0
$
0 0 2,3
B.&P.C: for this reason '/� REPAIR o �zr
Date:- - USE OF DEMOL ❑ 4.0•� ��d J.ci.�
EXISTING BLDG. '
Signature APPLICANT
(PRINT) TIEL.NO. lye FINAL 8i1 8.-88
OWNER-BUILDER DECLARATION / DATE
I hereby affirm that I am exempt from the Contractor's License •n
Law for the following reason (Section 7031.5, Business and ADDRESS (/� �T FIN
Professions Code): PRE EN By
❑ BUILDING
1, as owner of the property, or my employees with ADDRESS
wages as their so le'coin pensation,will do-the work and
the structure is not intended or offered for sale(Section LOCALITY ® ;2,0 5 4'8 A-
7044,iBusi;ness and Professions,Code). MOVING TEL. _
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- : ADDRESS "°;� 5 3 0 0
tion 7044, Business and Professions Code). -"
REQUIRED TOTAL SETBACK FROM
Z 2
CONSTRUCTION LENDING AGENCY" SET BACK YARD HWY PROP. LINE WIDTH - 0 - 1 5'3:0.0 5
I hereby affirm that there is a construction lending agency for FRONT
the performonce•of the work for which this permit is issued P.L. - !) a 2.9•`. 8 8
(Sec. 3097, Civ. C.). SIDE
P.L.
1 Lender's Name "
LDMA Ref.-f1
m _ .. P.C. Fee �• _ Permit Fee ". - ..
Lender's Address
3 _ - ``� `
$ I certify that.I have, this application and state that the Issuance Fee (Jo J CDMA P/C q
a above information is correct. I agree to comply with all County_ Investigation Fee
0 ordinances and St a laws relating to building construction, Total Fee 1 CDMA Perm. q
R and hereby auth ize representatives of this County to enter
M upon the above- ention property for inspect,pn purposes.
m
I SEE REVERSE FOR EXPLANATORY LANGUAGE
- ign ure f Appificint or'Agent Date - - - -