HomeMy Public PortalAbout9445 LAS TUNAS DR_Building_3/16/1989_Internal illuminating channel letters WORKERS COMPENSATION DECLARATION '
I hereby affirm that"I have a.certificate of consentao self p �T I•: I• R
nsure,
.1 e.6
Workers' Compensation Insurance; _!_; ®�; , ,O� i/u'.I L D I N' PERMIT
or a certifjed`copy thereof (Sec. 3800,:L.
C.); SA
10'85T3.2State Fund: COUNTY OF.LOS ANGELES BUILDING-AND: FETY
PolicyNo Company-
-7. BUILDING a
Certified'copy is"hereby fu Wished. FOR APPLICANT-T&FILL IN
BUILDING .:
® Certified copy is filed.with the county building inspee 944 La S T'Un S Dr 1 Ve
ADDRESS- 5 a
tion department:. ADDREss ' 9445 •Las" Tunas 'Dr. . TTeM le Cit" , 'CA. 91780
3-15-.89 TerrY .TO CITY' .'.2'2Til le " Clt ZIP 91780 LOCALITY 1 e�'
Date Appicanf N F BLDGS _
CERTIFICATE-•OF EXEMPTION FROM WORKERS'. ON SIZE OF LOT NOW LOT
COMPENSATION,INSURANCE` CROSS NEARESST.
ASSESSOR
(This section need not be completed if,the permit is fo"r one TRACT' " ' BLOCK' LOT NO. MAP BOOK PAGE PARCEL _
hundred dollars ($ OP)7 or less ) = :. TEL:._
OWNERNat`1"Onal CO NO" USE ZONE MAP
I certify.that in the performance-of the,wbrk for which this NO:
SPECIAL7 .
permit is issued, I shall not employ,any.person in any'manner ADDRESS .9445' as 'T CONDITIONS.
-
so as to become subject to the Workers Compensation Laws. O "
"I,
CITY -ZIP
Date' Applicant ARCHITECT OR TEL:;, .
NOTICE"TO,APPLICANT:, If,'- making this-Certificate of ENGINEER•; NO: P CONST ZONE ` .O0
DISTRICT -GROUP, PROCESSED BY
Exemption,' you should become• subject-"to the Workers' flu w
Compensation`provisions 6f.the Labor Code, you must forth- ADDRESS.>' rVU V '." �.o' a
with},comply with such--provisions or•this permit shall be TEL.. STATISTICAL CLASSIFICATION APT. CONDO
deemed revoked. CONTRACTOR' Signs. EX re'ss NO.-44.3 1:60.6. —
LICENSED•CONTRACTOR %DECLARATION;
LIC. CLASS.`NO._L_Q_DWELL•UNITS _ Z
I hereby affirm-that.Iam licensed under provtsions"of-Chapte.r9 ADDRESS"' 2446 'Kerced AVe NO. , 5 2 0,9 7, 1
(commencing with"Section 7000)of Division 3 of,'the Business MAP
LIC. •.
and Professions Code,and my-license is in full force and•effect., CITY CLASS 5 PG: A"iC F ULIDATION
. . SQ. FT. NO. OF NO _OF C4CHECK ..;
SEWER
5:52.097 BK:...
License Numbe"r ' ,' Lic.,Class C45•.. SIZE STORIES' FAMILIES ONE 4L
;,. �r1�a51
Signs Expres M
CO DESCRIPTION OF WORK NEW "`I _I
Contractor. � � XX }� Date 1 2—31=;9 0 i
VALUATION'.
. •a -880 0:0 0 � � t I:r,�
❑I am exempt.under Sec Internal 11lUr.C17aTlriel- cltr A TIt1L ,® —
DD
s
. _ :ALTER ❑
C:
B.8P.C. for this reason` S . lLr rE efl
Q Iz
Date:
" .. . USE OF •�. '- REPAIR
EXISTING BLDG: •in
. DEN10L,
Signature ' Terry
FINAL
• APPLICANT," '� - SEL...
OWNER-BUILDER DECLARATION (PRINT).' T2rY TO NO:.443 1_.606
I hereby affirm that I am exempt.from the Contractor's License ;Iutctrl = II7� �3 `�'t
Law.for the following,reason'(Section 7031.5, Business and ADDRESS 2446 Merced Ave� ,yS ..El rMOnte DNTE'
_ ' :0 -
Professions,Code):" �1
BUILDING
❑ I as owner of the property, "or my'employees with ADDRESS
wages as their,sole compensation;will•do-the-work and
•the"structure isnot intended or offered for sale(Section LOCALITY +e:'
7044, Business and Professions Code. MOVING TEL. "
0 I, as'owner,of the property,,am exclusively contracting
CONTRACTOR, NO.
,r with'licensed contractors o constructihe prolect'(Sec, ADDRESS
tion 7044; Business and Professions Code::)
REQUIRED- TOTAL`SETBACK'FROM EXIST.
CONSTRUCTION LENDING AGENCY.". . SET BACK YARD" 'HWY" PROP LINE WIDTH"
r
I hereby affirm that there is'a construction lending•agency for FRONT
_.'. the performance of the work for which"'this permit is issued P.L.' _
' (Sec. 3097, C,iv. C.): •SIDE
Lender's Name"
r
LDMA Ref #
PC:.Fee$ Permit fee . ' - -
3 Lender's Address
o (`certify that_I have read this application and`state that the Issuance Fee D� LDMA P/C'#- , �4.` y•
above information is correct.')agree to'comply with-all County In vestigation'Fee
N ordinances and"State laws relating Jo building construction, Total Fee (D (J LDMA Perm:'#
a and hereby authorize representatives of,thisCounty to enter
�. upon the above-mentioned.property foFjnspection,.pur`poses.
a .
"SEE REVERSE•FOR EXPLANATORY LANGUAGE
Signature of Applicanfor Agent Date