HomeMy Public PortalAbout9212, 9212 1/2 LAS TUNAS DR_Building__ WORKERS' COMPENSATION DECLARATION
` I hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
oraa certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PoPV 402 Company SepubIic ztsdlaeartity
❑ Certified copy is hereby furnished. jI FOR APPLICANT TO FILL IN BUILDING
ADDRESS
® Certified copy is filed with the county building inspec- [AUDRESSILDING
tion department.
t �
Date 11-•1`37 Applicant Rando2 Roofing zip LOCALITY �
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS. NEAREST
COMPENSATION INSURANCE IZE 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.) RACT BLOCK LOT NO. MAPBOOK PAGETEL. USE ZONE MAP 01 certify that in the performance of the work for which this WNER NO. NO
permit is issued, I shall not employ any person in any man r ��� iTe1�}� SPECIAL LLI
so as to become subject to the Workers'Compensation Lav . ADDRESS CONDITIONS
Date 9"13— 7ApplicantRBne�O1 Rocifina. CITY s ZIP
NOTICE TO APPLICANT: If, after making this Certificate of ARCHIENGINERT NO. DISTRICT, GROUP TYPE FIRE PROCESSED BY Q
Exemption, you should become subject to the Workers' CONST. ZONE 0:
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL. STATISTICAL.CLASSIFICATION APT. CONDO.
deemed revoked. CONTRACTOR NO. UJI
LICENSED CONTRACTORS DECLARATION LIC, — . CLASS NO. DWELL. UNITS F-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business apd LIC. SEWER MAP
Professions Code, and my license is in full force and effect.' CITY S;A CAbr1e1, Cd. CLASS r-•39 BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number $,4,_93'? Lic.Class r;. :t- SIZE JSTORiES FAMILIES ONE
Ran Aol Roof nex Ft. NEW ❑ VALUATION
Contractor Date 9- 7 DESCRIPTION OF WORK ,. FLtA mpnrtmp
— At?d C ADD $
❑ lt9P f1 ,
❑ I am exempt under Sec. &MOrt with �'ibererias
ALTER ❑
B.BP.C. for this reason REPAIR Q $
Date: EXISTING BLDG. DEMOL
Signature APPLICANT TEL. ,? FINAL
OWNER-BUILDER DECLARATION
(PRINT) Rranol Roaginq NO. � DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): R M By
BUILDING
❑ I, as owner of the property, or my employees with ADDRESS
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.
❑ 1, as owner of the property, am exclusively contracting CONTRACTOR. NO
with licensed contractors to construct the project (Sec- ADDRES6
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK ROM
SET BACK 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 '
3 510.5Q
$ I certify that I have read this application and state that the Issuance Fee LDMA P/C#
above information is correct. I agree to comply with all County nvesti anon Fee
0 ordinances and State laws relating to building construction, g' +
Total Fee
o and hereby authorize representatives of this County to enter ?7 .n� LDMA Perm. #
upon the above-mentioned property for inspection purposes.
m SEE REVERSE FOR EXPLANATORY LANGUAGE
n Signature of Applicant or Agent Date