HomeMy Public PortalAbout10161 LOWER AZUSA RD_Building__ ORKERS' COMPEN$ATION DECLARATION 1
Wj' ISK
hereby affirm that 'I have a certificate of consent to self
'insure, ora certificate of Workers' Compensation Insurance, APPLICATION, F,O R BUILDING PERMIT
or a certified copy thereof (Sec. 3800, lab. C.) \ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Compony
Certified copy is hereby furnished. FOR APPLICANT TO FILL W., BUILDING
ADDRESS
Certified copy is filed with the county building inspec- BUILDING r� f
tion department. ADDRESS
rr G f� we Wt a
Date Applicant CITY /gym 1,Q Cf ZIP LOCALITY c
CERTIFICATE OF EXEMPTION FROM WORKERS' O (�Y NO. OF BLDGS. j� NEAREST
COMPENSATION INSURANCE SIZE OF LOT O ✓ NOW ON LOT lY CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL.
r ($r�J ,009 USE ONE MAF
I certify that in the performance of the work for which this OWNER 'LF { e NO. �'T NO.
permit is issued, I shall not employ any person in any manner 24 ��� i��1 ( SPECIAL
ADDRESS v CONDITIONS
so as to become subject to the Work r 'Compensation Lawsmow . Q
X ,/ CITY ' gl ZIP �� U
Date N Applicant
r ARCHITECT OR �/ TEDISTRICT GROUP TYPE FIRE PROCESSED BY Q
NOTIC TO APPLICANT: If, after making t is Cer ficate of ENGINEER . in /(L44 N9.7191
L CONST. Zj F—
Exemption, you should become subject to the Workers' y[ II � U
Compensation provisions of the Labor Code, you must forth- ADDRESS DZ 1/�1 II e V/ 3 W
with comply with such provisions or this permit shall be
r TEL. ) STATISTICAL CLASSIFI ATION APT. N
deemed revoked. CONTRALTO � /b (,� �1��(, C�NO. ��� G�� J � �
LICENSED CONTRACTORS DECLARATION LIC, /, / CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Z �� e NO.
(commencing with Section 7000 of Division 3 of the Business and SEWER MAP �s
( 9 ) � j LIC.
Professions Code, and my license is in full force and effect. CITY �t�}j�)" CLASS BK / VALIDATION
SQ. FT.i y NO. OF NO. OF CHECK
License Number Lic.Class SIZE STORIES 2- FAMILIES ONE
yIL VALUATION
DESCRIPTION OF WORK NEW U
- Contractor Date ❑ ;
ADD
I am exempt under Sec. ❑
ALTER
B.&P.C. for this reason `f' Xf _ R A REPAIR $
Date: USE OF I ❑
EXISTING BLDG. DEMOL
Signature APPLICANT ��r�A NO ) -) FINA
OWNER-BUILDER DECLARATION PRINT b .
G DAT
I hereby affirm that I am exempt from the Contractor's License P 8 8 4,3.A
Law for the following reason (Section 7031.5, Business and ADDRESS ' Va �Y� FINA
Professions Code): P EN By # o 0 0 0��
BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and - 459.20
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL. s
CONTRACTOR NO. ° ° Jr 9,2 O
I, as owner of the property, am exclusively contracting '�;
with licensed contractors to construct the project (Sec- }' 2
tion 7044, Business and Professions Code). ADDRESS (]1.2 5,r 8 8
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
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. Q 5 Q,9 A
(Sec. 3097, Civ. C.). SIDE
P.L. #,0 0 °'0 0.�
Lender's Name
LDMA Ref. #
P.C. Fee$ 2 0 Permit Fee
Lender's Address f'� ° 7 8 2 2 5
3
g 1 certify that'I have read this application and state that the Issuance Fee /6-J L✓ LDMA P/C# ° a ]8 2,L1 Jr c��
above information is correct. I agree to comply with all County Inv sti .tion Fee
o ordinances and State laws relating to building construction, g
and hereby authorize representatives of this County to enter Total Fee LDMA Perm. # Q 8 2 3—8 8
udon the above-me tirw
perty for inspectio purpos s.
a
/21 SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ure of A plicant or Agent t Do e