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HomeMy Public PortalAbout10163 LOWER AZUSA RD_Building__ ;,',•,VyORKERS'COMPENSATION DECLARATION \ -type C� +r•hereby gaff cer that'I havecertificate of consent to self A P P L I CATION FOR BUILDING PERMIT �] 'insure, of a certificate of Worr kers' Compensation Insurance, or a certified-copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAF TY Policy No. Company BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS14 (� Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 0 Wor m!�GL Date Applicant CITY ['e t/oty ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF SIZE OF LOT 3G� O� �, NOW ON LOTS. © NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the permit is for one Q ASSESSOR hundred dollars ($100)or less,) TRACT / L BLOCK / LO7 NO. /I/ //L MAP BOOK PAGE�J PARCEL TEL.0 is b�2 —2l _ I certify that in the performance of the work for which this OWNER o f1 eS en NO.�' CX1t' USE VE��A P permit is issued, I shall not employ any person in any manner SPECIALi ADDRESS 2(�L � �e CONDITIONS so as to become subject to the Wor er 'Compensation L �s. p,'� U Date �� Applicant �� CITY ZIP a 0 + ARCHITECT OR i TELX DISTRICT GRO TYPE FIRE PRO ESSED BY O NOTI E TO APPLICANT: If, after making th• Certificate of ENGINEER Pi n' ( WCIn N04"�� Z 'G�Z' Exemption, you should become subject to the Workers' CONST: ZONE 0V Compensation provisions of the Labor Code, you must forth- ADDRESS 2b 2 , V J c U ✓ LU with comply with such provisions or this permit shall be a- deemed revoked. ¢ / TEL' Cd��jp7 LCOG STATISTICAL CLASSI C TION APT. CO fA CONTRACTOR x rd AGl�rl6 0 O. �7/ M� Z LICENSED CONTRACTORS DECLARATION. 7 1IC. / CLASS NO. DWELL. UNITS_, I hereby affirm that I am licensed under•provisions of Chapter 9 ADDRESS I ��. Va NO. �/ (commencing with Section 7000)of Division 3 of the Business and LIC j� SEWER MAP �.(Y Professions Code, and my license is in full force and effect. CITYAI& 111 ��� CLASS ^� BK PG ! Vgg�q �ro A SQ. FT.icj Z1 NO.OF NO. OF CHECK SIZE STORIES FAMILIES ONE VAL ATION License Number Lic.Class � # o o,o r° 2 3 DESCRIPTION OF WORK NEW $ ° 65600 Contractor Date ❑ ADD I am exempt under Sec. _ ALTER ❑ ­ 65600't) B.BP.C. for this reason REPAIR $ DEMOL Date: USE OF ❑ 01.25-88 EXISTING BLDG. ❑ Signature APP ICANPR NTT /7I "I�C, n NO.TEL. lb vw iw FINAL OWNER-BUILDER DECLARATION \\ ee'' ]s 99 DATE I hereby affirm that I am exempt from the Contractor's License. 2 .L tN V(j�� /g�� b N Law for the following reason (Section 7031.5, Business and ADDRESS FI Professions Code): PRESENT BY ❑ BUILDING Z� 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). 2.0 5 0,8 A CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETBACK FROM SET BACK -YARD HWY PROP. LINE .WIDTH 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$2 2 5 (Sec: 3097, Civ. C.). SIDE P.L. Lender's Name ° ° 7 8 2.2.5 5 LDMA Ref. #m P.C. Fee$ r Permit Fee �� p &2 3 -8 8 Lender's Address 3 _ " C, I certify that I have read this application and state that the Issuance Fee �, LO LDMA P/C N o above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee t 9 LDMA Perm. N and hereby authorize representatives of this County'to enter m up n he above-mentionMpo tyfor inspectioyn urrposses aIZ4 A/ SEE REVERSE FOR EXPLANATORY LANGUAGE Signat re f Appli ant or Agent ` Date