HomeMy Public PortalAbout9445 LAS TUNAS DR_Building_3/20/1990_demolition WORKERS'COMPENSATION DECLARATION
I' lie4b affirm thot 1 ho a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT '. u
or a certified copy thereof (Sec, 3800; Lab. C.) '
Company /e�7Ta/�T 1%z
Policy No�'.35033 �'o COUNTY OF LOS.ANGELES BUILDING AND SAFETY
Certified copy is hereby,furnished. _ 1 11 F R APPLICANT TO FILO IN BUILDING
ADDRESS v
❑ Certified copy is filed with the.county build' insp - BUILDING 71
tion
�department. ADDRESS /7 / nQs-�"/
Date '7r /¢ APPlica CITY- Ej�7 C/ ZIP LOCALITY
ERTIF(CATE,OF EXEMPTION FRO WORKER ' . NO. OF.BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT 22 NOW ON LOT- CROSS ST.
(This.sectiorr need not be.completed if the permit is for.,one � � ASSESSOR . ,
hundred dollprs.($100)or less.) TRACT SO Z BLOCK LOT"NO. MAP BOOK - PAGE, PARCEL
G/��� � �- TEL: USE ZONE MAP �
OWNER�/ NO.
I certify that in the performance of the work for which this NO. �JIJ
Permit is issued,.)shall not employ any person in any manner ADDRESS 1,!:60 0 v4=n iJ.29 8G[/a �CJ7 �ii7 ' , SPECIAL i
so as to become subject to the Workers'Compensation Laws. c CONDITIONS 0.
CITY !G'!/>O ZIP /%4 310 Z7�J V
Date" . Applicant
NOTICE TO APPLICANT: If, after makingthis Certificate- of ARCHITECT OR TEL. _�/3 DISTRICT OUP. TYPE FIRE PRO ESSED BY. O
ENGINEER �T�-� :` NO. - S CONST..
Exemption; you should become subject to the Workers'
Compensation provisions of the Labor Code,,you must forth- ADDRESS 3vac�3 ' .L sno�/7 �vE �/�`� �Z` W
with comply with.such provisions or this:permit shall be a
deemed revoked.
TEL. STATISTICAL CLASSIFICATION APT. ONDO. U)
CONTRACTOR .L.�GdR� 17 NO.-? -3'/63 ( - Z
LICENSED CONTRACTORS DECLARATION.. LIC. i CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ,07e' L� G/ls On.JS NO. 272-36GiLt'
(commencing with Section 7000)of Division 3 of the Business and LIC.1 SEWER MAP
Professions Code, and my license is in full force'and effect. CITY 7,54I /- �/J CLASS .8'—/ ' VALIDATION
SQ. FT. NO.OF - NO. OF CHECK BK. PG.
License Number 7Z 34"k, O Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
,K,q 6�n 4_ Sate OF_WORK NEW ❑
Contractor GP 4Date �¢
ADD ❑ $
ElI am exempt under Sec. oL
ALTER ❑ ( �939,3A
B:&P.C. for this reason REPAIR ❑ S
e: 'USE OF # o 9.0 e 0'1
EXISTING BLDG. Ae672-114_1r977 DEMOII
Signature A APPLICANT TEL.. �� 'l o 0 6 Q 5 Q
PRINT G7,G .�.Ai�G'4r7 No.az4 3/G3
OWNER-B ILO DECLARAT N 1
t I hereby.affirm.that I,am exempt from the Contractor's License 0;0 o 6 Q 5 065
.9 . 0 1i..9$ Ul7fiLS
Law for the following reason (Section 7031ADDRESS 7
..5, Business and FI
Professions Code): PRESE T to 4- 5 $8
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will old the work and
the structure is not intended or offered for sale(Section LOCALITY
7044; Business and Professions Code). MOVING TEL.: •- .•
❑ pop-
1, as owner of the property, am exclusively contracting CONTRACTOR N0. y
-with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,"Business and Professions Code).
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK -YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the'work for which this permit is issued- ' P.I.
(Sec. 3097;Civ. C.). SIDE
P.L.
Lender's Name
LDMA Ref. #
Lender's Address P.C. Fee$ Permit Fee. 5 t
I certify that 1 have read thi I' t* nand state that the Issuance Fee C rLDMA P%C#
o above information is'correct agree t comply with all County Investigation Fee �'`
0 ordinances and State law relating o buiIding.construction, o�. �'� t . 2 at `3d , G . -
and hereby uthorize re esentati es of this County to enter Total Fee` a LDMA,Permr q f o _ `4
upon thea v do prop rfy/for inspection purposes.
¢/2 SEE REVERSE FOR EXPLANATORY LANGUAGE l 3 a�
5$
Sig atur of Applicant or A ent --Date / '-
G 77 1 V e-4 41AP ��