HomeMy Public PortalAbout9945 LAS TUNAS DR_Building__ oY�
WORKERS' COMPENSATION DECLARATION
insure boraafcertif cafirm tharte of Worke srlComtpennsat oificae of n ent to
eself APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
FOR APPLICANT TO FILL IN BUILDING
❑ Certified copy is hereby furnished. � ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion department.
ADDRESS
Date Applicant CITY ZIP LOCALITY
pp NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL.
OWNER NO. USE ZONE MAP
.
I certify that in the performance of the work for which this NO
1 SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS t CONDITIONS
so as to become subject to the Workers' Compensation Laws.
CITY ZIP 0
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY U
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO.
CONST. � ZONE J
Exemption, you should become subject to the Workers' (r u.
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. ar
deemed revoked. CONTRACTOR NO, Q
LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS CX
ADDRESS
1 hereby affirm that I am licensed under provisions of Chapter 9 NO. SEWER MAP CL
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION Fw—
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW
ADD ❑ $
poll.
I am exempt under Sec. ALTER ❑
B.BP.C. for this reason REPAIR ❑ $
Date: USE OF DEMOL F]EXISTING BLDG.
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT) 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): PRESENT 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.
❑ ,I, 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 YARD HWY TOTAL SETBACK FROM ILDMA
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE
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
P.L.
Lender's Name
+� A Ref. #
P.C. Fee $ Permit Fee ,
� Lender's Address
0 1 certify that I have read this application and state that the Issuance FeeA P/C#
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee Perm. #
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
a
o SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date J