HomeMy Public PortalAbout10165 LOWER AZUSA RD_Building__ WORKERS'COMPENSATION DECLARATION / - C-
it sure, o a cer that 'I haver certificate of consent to self APPLICATION FOR BUILDING PERMIT
rinsure, of a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company _ BUILDING
Pol
Certified copy is.hereby furnished. FOR APPLICANT TO.FILL IN
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDINGy� µn
tion department. ADDRESS CA W,& = I 1 IvU S jA
Date_ Applicant CITY e t t4 ZIP f� LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT �O U S. j�•NOW ON LOTNO.OF S C/ NEAREST
COMPENSATION INSURANCECROSS ST.
(This section need not be completed if the permit is for one p. Z ASSESSOR
hundred dollars ($100)or less.) TRACT 7 1 BLOCK LOT NO. aE MAP BOOK PGE PARCEL
/ TEL. ow USE Z NE MAP �1
I certify that in the performance of the work for which this OWNER RO 7(! �1. Yh NO. Z NO. �?C
permit is issued, I shall not employ any person in any manner SPECIAL
ADDRESS C 9 C `��/ OL CONDITIONS
so as to becom sub'ect to the Work r 'Comp��Ma4
� U
CITY Gl ZIP
Date Applicant_ / �-
ARCHITECT OR TEL.f/� 1 DISTRICT GR UP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making s' C rtificate of ENGINEER h I�Jfn11 NO.L �x) 0�` Q
Exemption, you should become subject to the Workers' f f ) CONST. ZONE U
Compensation provisions of the Labor.Code, you must forth- ADDRESS 2 �_ ( !V� jlti`/ W
with comply with such provisions or this permit shall be TEL. CG W,
deemed revoked. STATISTICAL CLASSf[IC�ITION APT. CO N
CONTRACTOR �)) (�kr/ NO. U�� Z
LICENSED CONTRACTORS DECLARATIONZ r., I t /�i LIC. 3 CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed•under provisions of Chapter 9 ADDRESS > Wt 1J l 16 NO.
�r
(commencing with Section 7000)of Division 3 of the Business and j LIC SEWER MAP
--C. 6 iiF— .
Professions Code, and my license is in full force and effect. CITY ah) N7 CLASS V/ VALIDATION
SQ. FT. 2Z JNO. OF NO. OF ' CHECK
License Number Lic.Class SIZE STORIES FAMILI ONE
p VAL TI�'N/ /�
DESCRIPTION OF WORK NEW //n 3 V z 8 8/L 6 A
Contractor Date $ !$ v �:
❑ 1 am exempt under Sec. �! ADD 0 loll.
# 0 0 0 0 2 3
ALTER
B.BP.C. for this reason REPAIR ❑ $ 1 - 62730
Date: USt OF DEMOL ❑ 6 2 7_.3 0 c=,
EXISTING BLDG. o 0
Signature APPLICANT ^ TEL. �S l _Z� FINA
"�
OWNER-BUILDER DECLARATION PRINT Q!7 NO. // DAT �` O.L2 5 8 8
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and ADDRESS Zv 2-- FIN
Professions Code): PRE ENT B
❑ 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 1
7044, Business and Professions Code). MOVING TEL. t
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec-
ADDRESS
tion 70Business and Professions Code).
44
REQUIRED TOTAL SETBACK FR
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT # .Q• .4
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE .
P.L. J 074a5'0
Lender's Name /' '`�]22 ® � 7 4 8.5 0 5)
P.C. Fee$ 6 2-7t Permit Fee /c! t LDMA Ref. # 0 a23-88
Lender's Address
oI certify that I have read this application and state that the Issuance Fee O 1� LDMA P/C#
g above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee, c�V LDMA Perm. #
o and hereby authorize representatives of this County to enter.
r e above-m Wned;perty for inspection purposes.
y SEE REVERSE FOR EXPLANATORY LANGUAGE
Signal efof A plicant or Age Do e