HomeMy Public PortalAbout10157 LOWER AZUSA RD_Building__ .;WOPKERS' COMPENSATION DECLARATION
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i,hereby %affirm that' I' have a certificate of consent to self A P P L'L %AT I O,N'=F®R' B U I L D I N G PERMIT
insure, or•o certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) ;COUNTY`OF LOS ANGELES, BUILDING AND SAFETY
Policy No. Company
BUILDING
❑ Certified copy is hereby furnished. FOR AP.PLICANT•TO'.FILL 1N' ADDRESS V `
❑ Certified copy is filed with the county building inspec- BUILDING Q/
tion department. ADDRESS
Date Applicant CITY --� 1.11 E C ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' INO.OF/� S,F NOW ONLLo S. ® NEAREST
Q
COMPENSATION INSURANCE SIZE OF LOT CROSS ST.
/ Q ^ ASSESSOR
(This section need not be completed if the permit is for one TRACT /0/ Z BLOCK LOT NO. J �!f MAP BOOK PAGE PARCEL
hundred dollars($100)or less.) •�-
OWNER Lille �J�'111i NO. No.USE ZONE MAP r 1 2,
I certify that in the performance of the work for which this \\II qq f SPEC
PE
permit is issued, I shall not employ any person in any manner ADDRESS �G Z LVf'• �l/1��(' 3 SPECIAL
CONDITIONS
so as to b come subject to the Wor Comp ensatio L s. j(`�� U
CITY m ZIP I �/
Date U� Applicanit v ��
ARCH ITECT ORT TEL/ '
NOTI TO APPLICANT: If, after makin this ertificate of ENGINEER N ��� -�/ � DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption,
you should become subject to the Workers / Q _` CONST. ZONE 1••'
Compensation provisions of the Labor Code, you must forth- ADDRESS zG l�' A'� j/�� / / W
with comply with such provisions or this permit .shall be yy,,�� JEL. STATISTICAL CLASSIFICATION APT. DO. Z
deemed revoked. CONTRACTOR � iWCA SeCicr'� /hN0.ovo-q j')Xq
LICENSED CONTRACTORS DECLARATION Z 1�� LIC. 7 7/ CLASS NO. 0—5 DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS / VV V06 /E NO. T
(commencing with Section 7000)of Division 3 of the Business and Q L LIC. SEWER MAP p }�
Professions Code, and my license is in full force and effect. CITY /l 0n � CLASS B - PG / ��� Y"A�IDAf ON2 3
SO. IT./7/u k I NO. OF NO. OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE ,J 0 4 3 5I 0
�j,Z VALUATION Ej �)
Contractor Date DEGSC PTION OF WORK A D -❑ $
( / ! o - 435,10'
❑ I am exempt under Sec. Q' ALTER ❑ lJ 1'2 5 d 8 8
B.i3P.C. for this reason te REPAIR ❑ $
Date: USE OF
'
EXISTING BLDG. DEMOL
Signature APPLICANT
'�lFv-Z
�❑ FINAL
OWNER-BUILDER DECLARATION PRNN
DATE /
I hereby affirm that I am exempt from the Contractor's License 1
Law for the following reason (Section 7031 Z.5, Business and ADDRESS l T � 1rc� FI
Professions Code): PRE ENT i
❑ 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 �' 0 5 07 A
7044, Business and Professions Code). MOVING TEL.
� I, as owner of the property, am exclusively contracting CONTRACTOR NO.
LA with licensed contractors to construct the project (Sec- ADDRESS \
tion 7044, Business and Professions Code). 1 - 74.1.7 5
REQUIRED TOTAL SETBACK F 11111..
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY. PROP. LINE WIDTH 2
I hereby affirm that there is a construction lending agency for FRONT ° ° 7 4 1.7 5 v
the performance of the work for which this permit is issued P.L. O 8 2 3`8 8
(Sec. 3097, Civ. C.), SIDE
P.L.
Lender's Name
LDMA Ref. #
m P.C. Fee$ V5,1 / Permit Fee
Lender's Address
3
g I certify that I have read this application and state that the Issuance Fee /0—SO LDMA P/C iF
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
N an hereby authorize representatives of this County to enter
u -4he above-ment onedq7rty for inspection rposes.
a SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur oftAppl cant or Agent Date'