HomeMy Public PortalAbout10155 LOWER AZUSA RD_Building__ ki9v4RiERS'COMPENSATION DECLAOATION �N,-
� ' I ere�e'6�r�;m that 1 'have a certificate of consent to self i
insure,, or-•.t'certificat'e of Workers' Compensation Insurance, APPLICATION - F C�R BUILDING PEI\i�I T u
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 BUILDING
ADDRESS
❑ Certified copy is filed-@vith the county building inspec- BUILDING 1
tion department. ADDRESS �^' 1 ow e V
Date Applicant CITY JO 10 (. ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' // NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT J &O NOW ON LOT O CROSS ST.
(This section need not be completed if the permit is for one O i /� ASSESSOR
hundred dollars ($100)or less.) TRACT U BLOCK ! LOT NO. MAP BOOK PAGE PARCEL
�^f TEL.)�rsl� •loa USE ONE MAP
1 certify that in the performance of the work for which this OWNER (( NO.L
permit is issued, I shall not employ a y person in any mannerSPECIAL
so as to become subject to the Wor s'Compenso ion Laws. ADDRESS L) ley CONDITIONS
U
Date �� Applicant CITY ZIP r 0
ARCHITECT OR / TE . DISTRICT G UP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this' Cer ificate of�, '� 1��) 23_0,
ENGINEER 7q WA N ^ CONST. ZONE U
Exemption, you should become subject to the Workers' �n 1 } bj d
Compensation provisions of the Labor Code, you must forth- ADDRESS:•�- 2 v1), lr� f� v` v W
with comply with such provisions or this permit shall be GS
TEL. /�7 STATISTICAL CLASSIFICATION APT. 127DO. N
deemed revoked. CONTRACTOR Q tp a 1 1 "NO.�819 / `—
LICENSED CONTRACTORS DECLARATION ( CLASS NO. DWELL. UNITS
2d1 Z `` f LIC. r' ) ?
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS V�� �'�! e NO.U�/ /13
(commencing with Section 7000)of Division 3 of the Business and �n1 LIC. j� SEWER MAP
c Professions Code, and my license is in full force and effect. CITY m CLASS / ALIDATION
SQ. FT.)C- NO. OF 2 1 NO. OF CHECK
'icense Number 1 Lic.Class SIZE .,7 STORIES FAMILIES ONE
G — VALUATION
GopiractorDate DESCRIPTION OF WORK NEW
D ❑ $
g2 8 g L1 5 A
-❑ I am exempt under Sec. ��' '`� ./�S� ALTER ❑
' ° ° ° °
B.BP:C. for this reason REPAIR ❑ $ # 23
Date: USEOF BLDG. \ J DEMOL ❑ 1 ° G 3 9. 1 it
-EXISTINSignature APPLICANT TEL 6 FINAL o o =
OWNER-BUILDER DECLARATION PRINT G (/� ` NO.` � �G _� DATE — 4 3 9. 1 .1 5
I hereby affirm that I am exempt from the Contractor's License ADDRESS Ti Z v � ' PIN O 1.2 5 r'8 8
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENTB
❑ 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. 22 050.4 A
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). # 0 0 0 0 0 1
REQUIRED TOTAL SETBACK F
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ) ° 7 4 a 5 0
1 hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this.permit is issued P.L. 7 4 8.5 0 6(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name 0 8 2 3 8 8
//(( LDMA Ref. #
m P.C. Fee$ JTqt / Permit Fee ti5
Lender's Address
3 jO,$ I certify that I have read this application and state that the Issua ce Fee J 0 LDMA P/C#
o above information is correct. I agree to comply with all County Investigation fee
0 ordinances and State laws relating to building construction, y— ?.
R and hereby authorize representatives of this County to enter Total Fee LDMA Perm. #
up n he above-mentioned proper tr y for inspection purposes.
4 ^/ �•r �Tj /J2 �j/ SEE REVERSE FOR EXPLANATORY LANGUAGE
(/ Sign—&u of'Applicant or Agent / Date r
y l
r �