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Home My Public Portal About9536 LAS TUNAS DR_Building__ _ � a WORKERS' COMPENSATION DECLARATION' insure, or acertificate affI have a certificate of irm of Workers; Compensation insuranceof APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy-No. Compariy BUILDING j ❑ Certified copy is hereby furnished. .. FOR APPLICANT TO FILL IN ADDRESS)c- ❑ Certified copy is filed with the county building inspec- BUILDING �/— tion department. ADDRESS �(�,� 44— Cel ` Date A licont CITY' / esti ZIP LOCALITYP 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 I PARCEL hundred dollars ($100)or less.) TEL. _ OWNER r NO. 1/ °a USE ZONE MAP I certify that in the performance of the work for which this [NO. } permit is issued, I shall not employ anyperson in any manner ADDRESS o CONDITIONS CL so as to become subject to the Workers'Compensation Laws. CITYZIP C�/- U Date Applicant ARCHITECT OR r TEL. DISTRICT GROUP TYPE FIRE PROCE ED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST ZO Exemption, you should become subject to the Workers' u C Q a- Compensation provisions of The Labor Code, you.must forth- ADDRESS - "° (7 N with comply-with such provisions.or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CO DO. Z deemed revoked. CONTRACTOR NO. r — LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. 117,9 DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO' SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC' and Professions Code,and my license is in full force and effect. CIN' CLASS BK PG. VALIDATION SQ. FT. NO. OF O. OF CHECK . License Number Lic. Class—' SIZE STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK �� O NEW ❑ Contractor Date $ ' ADD 10 - , E:1I am exempt under Sec. - ALTER ❑ BAP.C. for this reasonREPAIR 1 $ Date: USE OF. DEM L ❑ EXISTING BLDG. Signature APPLICANT Fr= 4)rvWA,,4e r d o COTEL. f FINAL (PRINT). N0. ��/ J-�� OWNER-BUILDER DECLARATION r DATE �j—rrL ._ �• s I hereby affirm that I am exempt from the Contractor's License or + U^( °a �' �Pia�i�iv. IIJ.+/ Law for the following reason (Section 7031:5, Business and ADDRESS Ucf- FINALf .7 P,r essions Code): PRESENT By NG 1-D I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and at the structure is not intended or offered for sale(Section LOCALITY , T TAI 69 � 92 7044, Business and Professions Code.) MOVING TEL uL�C ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. CHECK 69.92 with licensed contractors to construct the project(Sec ADDRESS `-•HANGt .013 tion'7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT Jzl t_i_00101 11/ 6 it 2 the performance of-the work for which this permit is'issued P.L. _ - (Sec. 3097, Civ. C. / SIDE. h.1f i AM 9: s Lender's Name G'� l /G /f ( r_f!..✓f%L_ P.L. LDMA Ref. # Lender's Address�� /� �u� ,� i>/! �Zf �C1j P.C. Fee$ Permit Fee J 1 1'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 In Fee. q 8 ordinances and Slate laws relating to building construction, Total Fee /• LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. JlSEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant orAgent �. Date .. WOVERS' COMPENSATION DECLARATION ( hereby affirm that I ihave a.certificate.of consent to'self .A P P.L I CATION FOR g U I L D I,N O` PERMIT' / insure, or a•certificate of Workers Compensation Insurance, ` .. or a'certified'copy ?hereof (Sec.'3800;Lab: C.) 1 COUNTY.OF LOS ANGELES BUILDING AND SAFETY - Policy No. Company BUILDING / ❑ Certified copy•is hereby furnished: FOR APPLICANT TO FI LL:I N' ADDRESS' o (O;' ,- • oy-� ' BUILDING ❑ , Certified copy is#iled,withahe county building inspec {t t tion.depariment., ADDRESS '. t,. Date Applicant J NO OF BLDGS.,: LOCALITY CITY' NEAREST CERTIFICATE,OF°.EXEMPTION FROM WORKERS. SIZE OF LOT NOW ON LOT E CROSS ST., {. f 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� ! ' / r NO., USE ZONE MAP , I certify-that'in,the performance of the work for which this• SPE ermit is issued; I shall not em to an erson"in an manner• ADDRESS' r M.f.,. SPECIAL ' P P. Y Y P Y. � �� CONDITIONS so as'to become subject t'o the Workers'Compensation taws CITY: ♦ i a ZIP f -r} d Date Applicant ARCHITECT ORl' TEL. DISTRICT GROUP' :TYPE FIRE PROCESSED BY 0 ENGINEER NO. ' 'NOTICE TO APPLICANT:, If;-after making' his Certificate of ' CONST rZgNE J Exemption � you should. become subject to the Workers'" ;f Compensation p'rovisions of the:Labor Code,-you must forth-. ADDRESS I' « `� u with comply .with'such provisions or this permit,shall be - TEL STATISTICAL CLASSIFICATION,• _ APT. CONDO. } deemed revoked: CONTRACTOR ''NO. f `LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. f-' DWELL. UNITS 1 hereby affirm.that 1 am licensed under provisions'of Chapter 9 ADDRESS NO' SEWER MAP (commencing with Section 7000)of Division 3 of'the Business LIC. and Professions Code'-and;my license is in full force and effect. CIN r . CLASS BK: PG. VALIDATION F SQ. FT. NO. OF 'NO. OF CHECK License Number Lic. Class SIZE STORIES FAMILIES ONE - VALUATION" DESCRIPTION OF WORK NEW ❑ Contractor Date_ S - !: ADD ❑ ❑1 am exempt under'Sec „ 1 , y - ► • _ ALTER . ❑ ---r•� B.BP C forthis reason REPAIR ❑ E ' Date: USE OF EXISTING BLDG. DEMOL ❑ \ Signature FINAL tl ;, APPLICANT TEL. OWNER-BUILDER DECLARATION ' (PRINT). NO. DATE s ' I hereby affirm thatI am exempt from the'Contractor's License '" -Z .- ' Law for the following reason (Section 7031.5, Business and ADDRESS FINAL F 4 _ Professions'Code) -. PRESENT BY BUILDING. / t } fJ I, as owner of-the property or mV employees with .ADDRESS 3' j wa es as their sale com ensation,will do the work and c I 1,'" „" thestructure is not intended or offered for sale(Section LOCAtI7Y. //1 C 7.044, Business:an-d Professions Code.) MOVING ; TEL. __ _- - 0 I, as owner'of the property, am exclusively contracting CONTRACTOR., NO. % with licensed contractors toconstruct,the project (Sec ADDRESS t•?91; tion 7044,.Business and,Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. . CONSTRUCTION LENDING AGENCY SET BACK. YARD HWY PROP. LINE WIDTH . I hereby affirm that there is a construction lending agency.for FRONT g E, (-� 'the performance of the work for which this permit,is issued •: P.L., t ,l (Sec. 3097',Civ. C..), SIDE _ e r P-.L.' Lender's Name 5✓ LDMA Ref. # r � - r i`"";` P C'Fee$ Permit Fee � • Lender's•'Address c -. r :• ' ' ? f LDMA P/C# o Issviance Fee ' o I certify that I.have read this application-and state.that the '• - , above information is correct. I agree to cornplywith all County Investigation Fee 8 ordinances and'State laws-relating to building-constructio'n,.' Total Fee !' '{ ^ LDMA Perm. # < ' and hereby authorize representatives of.this County to enter _ M upo,•-,n tthe dbove;mentioned property for inspection,purpos-S. o �. r.,.:' '+ SEE REVERSE,FOR EXPLANATORY LANGUAGE .. - Signature of Applicant or Agent - Date" -` - - - - - -