HomeMy Public PortalAbout9032-9034 LAS TUNAS DR_Building__ WORKERS' COMPENSATION DECLARATION
I herebyinsure'oraffa certif cairmrte ofave Workers' Compensat on Insurance, APPLICATION FOR BUILDING PERWI T
or a certified copy thereof (Sec 3800, Lab C ) "
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN
PoliBUILDING
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING O` 2 �A
tion department ADDRESS
�,�' JCS' u J
Date Applicant CITY / ✓ i ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS'' NO OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW 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
EE7 / ]PARCEL
I certify that in the performance of the work for which this
OWNER % �/�/L Npp�0�0 Z USE ZONE NO l O !/b
permit is issued, I shall not employ any arson in any mann y/] ��`1 �G�� SPECIAL
so as to become sublect to the Wor s Co e a a ADDRESS / r O e L r��,., CONDITIONS U
Date-4— ?Applicant �� CITY �� O��iEy ZIP
NOTICE TO APPLICANT: If, after along this Cer cate of ARCHITECT OR TEL
fDISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers' ENGINEER CONST ZONE U
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EL STATISTICAL CLASSIFICATION APT I thNDO to
deemed revoked NO
LICENSED CONTRACTORS DECLARATION �'� 0 No' y� loo2� CLASS NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE 7 EWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC Q
Professions Code, and my license its in full force arid'effect CITY f/ G!!�� CLASS C / BK PG VALIDATION
,3.5't a�•2. -�9 SI STORIES FAMILINO LIIES CHECK
License Numb Class SIZE' - VALUATION
��7 DESCRIPTION OF WORK G- /' NEW ❑
Contractor ate / 2v,
AADD ❑ s pill
am exempt under Sec c v ❑
_ L R
B.BP C. for this reason �� D �wQ/�l/� WPAIR :
rUSE OF
to EXISTING BLDG Ch S DEMOL ❑
Signature - APPLICANT TEL FINAL
O NER-BUILDER DECLARAT PRINT NO DATE / 0 8 7.5 A
I hereby affirm t at I am exempt from the ontractar's License
Law for the fol owing reason (Section 7031 5, Business and ADDRESS cc�u�� /-� FI
o o • • ail
Professions Co e)-
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS ° 09675
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code) MOVING TEL o o'o 9❑ 6,7 5 5
I, as owner of the property, am exclusively contracting CONTRACTOR NO v
with licensed contractors to construct the project (Sec- ADDRESS Q 071`,8 8
tion 7044, Business and Professions Code)
'CONSTRUCTION'LENDING AGENCY SETT BACK YARD HWY iRED TOTAL SETBACK
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 L
(Sec 3097, Civ C.) SIDE
PL
Lender's Name
m LDMA Ref #
PC Fee$ Permit Fee r Z
Lender's Address
I certify that I have read this application and state that the Issuance Fee ( O LDMA P/C# Poo
9 above information is correct I agree to comply with all County Investigation Fee
S ordinances and State laws relating to building construction, Total Fee 175 LDMA Perm #
R and hereby authorize representatt s of this County to enter
m upo a me t o pr r fo nspection purposes
< SEE-REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or nt Date