HomeMy Public PortalAbout9676 LAS TUNAS DR_Building__ i
WORKERS'COMPENSATION DECLARATION 860714 BG
I hereby affirm that I have r certificate of consent to!self "P L I CAY��N Ti -3 U� I PERMIT
insure, or a certificate of Workers'Comperisation Insurance, �✓
or a certified copy thereof(Sec. 3800, Lob..C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NF00071 66 Company Beaver Ins. 01o. BUILDING _
Certified copy is hereby furnished.. FOR APPLICANT TO FILL IN ADDRESSYb
�• 1lGd�
( Certified copy is filed with the county building inspec- FADDRESS
u tion department. I' 76 E. Las Tunas LOCALITY L /ElNEAREST
Date 12/8/86 Applicant Virgin Roof CO._ m le -Cit ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE NOW ON LOT " MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one �� USE ZONE MAP
hundred dollars ($100)_or less.) TRACT BLOCK LOT NO. i, NO.
TEL. i', !Y SPECIAL
OWNER Dr. Chandler NO. V CONDITIONS 9L
I certify that in the performance of the work for which ithis DISTRICT TUP
TYPE FIRE PR C SED BY O
permit is issued, I shall not employ any person in any mariner ADDRESS as above J) � CONST. - ZONE V
so as to become subject to the Workers'Compensation Ldws. U
Date Applicant I CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO.
NOTICE TO APPLICANT: if, after making this Certificate of ARCHITECT OR TEL.
ENGINEER NO. CLASS NO. 24 DWELL.UNITS
'Exemption, you should 'become subject to the Workers'- p,
Compensation provisions of the Labor Code, you must forth- -
with comply with such provisions or this ADDRESS SEWER P
p y p permit shall I be \ z
deemed revoked. Vir in Roof Co TEL-287 BK.L/ PG,/ VALIDATION
CONTRACTOR g NO.
LICENSED CONTRACTORS DECLARATION . . LIC' 160650
I hereby affirm that I'am licensed under provisions of Chapter 9 ADDRESS p,0 BOX J NO. VALUATION
(commencing with Section 7000)of Division 3 of the Business and S 'Gabr ie 1 LIC' C39 $ 1498.00
Professions.Code,aan
nd my license is in full force and-effect. CITY CLASS
160650 l ° SQ.FT' 650 NO.OF NO. C
1Ta11 HECK
License Number Lic.Class C39 ;SIZE STORIES FAMILIES ONE
Contractor Virgin Roof CO DESCRIPTION OF WORK Partial re—roof: NEW ❑ $
Date 12/8/86, -
I am exempt under Sec. i Tear off and re—roof 2 lower r oFALTER O FINAL
49
B.6P.C. for this reason ' at front W/ 1 ��30 s 3 #15, 1 ��7 REPAIR ❑I DATE /, IS 1 3 2 A
Date: Lan roc 621 sqs. DEMOL
'#EXISTING BLDG. ❑ /� # o a o o,o.1
Signature APPLICANT Vir in Roof Co T87-0507
OWNER-BUILDER DECLARATION PRINT $ N . 1 0 o49,88
I hereby affirm that I am exempt from the Contractor's License P.0. Box J San Gabriel 91778
Law for the.following reason (Section 7031.5, Business and ADDRESS s D x
a aV
Professions Code): PRE ENT a49,.88
❑
I, as owner of the property, BUILDING
or my .ADDRESS 12,1 8=8 6
wages as their sole compensation,willemployees'with 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- ADDRESS
'tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP, LINE WIDTH D
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.
tSec. 3097, Civ. C.). SIDE
m 'P.L:
v Lender's Name
- Lender's Address
P.C. Fee$ Permit Fee 39.38
x I certify that I have read this application and state that the Issuance Fee. 10.50
above information is correct. I agree to comply with.all CountyInvestigation Fee
ordinances and State laws relating to building construction, Total Fee 49.88
7 and her by authorize representatives of this County to eriter -•....
upon th above-mentioned pro rty fol-inspection purpo s.
' ' �� SEE REVERSE FOR EXPLANATORY LANGUAGE
"9nof Applicant or Agent Date ,
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