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HomeMy Public PortalAbout10167 LOWER AZUSA RD_Building__ WORKERS'COMPENSATION DECLARATION I to self insure boor afirm certif certificate of Workers' Compensation that I have a certificate ofconsent Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) 5 to `� COUNTY OF LOS ANGELES BUILDING AND SAFETY Po icy No. Company f Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING 6 s ADDRESS ti Certified copy is filed with the county building inspec- BUILDING tion e department. ADDRESS `o/G 7 Gy e %q<,rk Date Applicant SVnp (AV"\ CITY / ° �J ty ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT L7 K NOW ON LOT CROSS ST. r� (This section need not be completed if the permit is for one Q ' � ASSESSOR hundred dollars ($100)or less.) , TRACT © / Z: BLOCK LOT NO. MAP BOOK S PAGE 012-1p ARCEL �Z TEL r I certify that'in the performance of the work for which this OWNER ar e, o e // II, NO. � US�/yZONE �P permit is issued, 1 shall not employ any person in any manner ADDRESS Z VV VDL I1f 6/vel, L}� SPECIAL so as to become subject to the Workers'Compensation Laws. nn �f u 1 CONDITIONS 0 CITY A In LL v\ �// ZIP V Date Applicant ARCHITECT OR ` N IS � DISPTR�ICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after makingthis Certificate of J CONST. ZONE V Exemption, you should become subject to the Workers' ENGINEER r / � .� Compensation provisions of the Labor Code, you must forth- ADDRESS Z$Z �[� w with comply with such-provisions or this permit shall be p/ a.' TE 0/� STATfSTICAI CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR N . .j G�pd Z LICENSED CONTRACTORS DECLARATION / CLASS NO. DWELL. UNITS..� /LIC. ' I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS A �� J NO. 7�� (commencing with Section 7000)of Division 3 of the Business and /� LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY G�YN� G'1 CLASS BK VALIDATION SO. FT. NO.OF NO. OF CHECK License Number �7/ 7r/3 Lic.Class 1 SIZE STORIES FAMILIES ONE r�� VALUATION C'^1t jl�-- ►OSP V• J►j �nDESCRIPTION OF WORK j (� -On NEW $ Contractor Dat 4fADD I am exempt under Sec. and cka)- ALTER B.BP.C. for this reason G+7 REPAIR El $ Date: USE OF DEMOL EXISTING BLDG. APPLICANT TEL jjj FINAL 8 7 1'6 • Signature A © ° o,®,© 'OWNER-BUILDER DECLARATION PRINT Gi /A NO/. i e� 1�'✓��j DAT # i I hereby affirm that I am exempt from the Contractor's License ADDRESS VVI a �' (Yo' /7 '/�U1 ( ° 060.50 Law for the following reason (Section 7031.5, Business and FI Professions Code):. O`` ©��� BUILDING /GAm ° ° ° b Q 5 0 I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ® 0 1.0 6 8 7 the structure is not intended or offered for sale(Section LOCALITY 7044, Business and'Professions Code). MOVING TEL. aI, 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). CK FROM CONSTRUCTION LENDING AGENCY SETBACK YARD HWY TOTAPROP.ALINE 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. (Sec. 3097, Civ. C.). SIDE P.L. \ Lender's Name ,Op i P.C. Fee$ Permit Fee LDMA Ref. # Lender's Address 3 o I certify that I have read this.application and state that the Issuance Fee -J-7) LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee a• r ': 0 ordinances and State laws relating to building construction, hd and hereby authorize representatives of this County to enter Total Fee LDMA Perm. # ;. up o .t a abov entioned property for inspection purposes. P; n r U SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Applicant or 4aVF Date 'VORKERS' COMPENSATION DECLARATION I 14k ' -hereby!c f irm that'l have a certificate of consent to self 'insure, o'r a certificate of Workers' Compensation Insurance, APPLICATION. - FOR B U L D I N G PERMIT or a certified copy thereof (Sec. 3800, Lob. C.) • :COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING r' Certified copy is hereby furnished. FOR APPLICANT�JO FILL'IN ADDRESS (f Certified copy is filed with the county building inspec- BUILDING ADDRESS �� tion department. ' ct F Date Applicant CITY ' fe ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' ® O $ T NO. OF BLDGS. SIZE OF LOT /� NEAREST COMPENSATION INSURANCE NOW ON LOT V CROSS ST. (This section need not be completed if the permit is for one //� ` ASSESSOR hundred dollars ($100)or less.) TRACT l A j �2-' ^BLOCK LOT N(O../p! MAP BOOK PAGE PARCEL (� .L It S EM NO.`"'&S7�Z USE Z E MAP I certify that'in the performance of the work for which this OWNER ® 1 / / NO. permit is issued, I shall not employ any person in any manner ADDRESS Z�j VVley SPECIAL . so as to become,subject To the Work rs'Compensation La s. CONDITIONS U _ CITY ZIP 0 Date Applicant ARCHITECT OR L TEL. NOTICE TO APPLICANT: If, after makingthis Ce ificate of I rr (f�f DISTRICT GROUP TYPE FIRE PROCESSED BY C) ENGINEER Tn Oen NO\� J L .`} CONST. ZONE I� Exemption, you should become subject to,the Workers' rf I �.0 (� Compensation provisions of the Labor Code, you must forth- ADDRESS 7- Z w- bC4i1e r f� v 5 with comply with such provisions or this permit shall be CL deemed revoked. CONTRACTOR ]0 �+ �'� ��iNO�°�� 6 �O�L STATISTICAL CLASSIFICATION APT. CONDO. U) LICENSED CONTRACTORS DECLARATION ��Z r� t t{ ! e NCO,, y��J� CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS V�f 1/ / / SEWER MAP (commencingwith Section 7000 of Division 3 of the Business and Q �� - rofessions Code, and my license is in full force and effect. CITY !`I lba CLASS BK 7 VALIDATION SQ. FT.,1796,2 NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE •toile. NEW )6VALu ION 'l 8 8 4 s1 A Contractor Date DESCRIPTION OF WORK J DD ❑ $ L U # o 0,- ,o ° 1 8 I am exempt under Sec. dLtZIAL ALTER E] , f ° 6 2:1.5 7 B.BP.C. for this reasonaAP REPAIR Q $ Date: US OF DEMOL o 0 6 2 1.5 7 EXISTING BLDG. , Signature APPLICANT on P C%�� TEL I S' 2 000 FINAL _ o 1.2 5 ii 8 8 NT OWNER-BUILDER DECLARATION DAT I hereby affirm that I am exempt from the Contractor's License ADDRESS fA e ��� hB FIN Law for the following reason (Section 7031.5, Business and Professions Code): - PRESENT By aBUILDING 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 sole(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO. \ y \ with licensed contractors to construct the project (Sec- -ADDRESS tion 7044, Business and Professions Code). .6.A' REQUIRED TOTAL SETBACK F 2'O:ij I 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. . Sec. 3097, Civ. C. SIDE ( ) P.L. ;i °74.. .1,75 � Lender's Namex P.C. Fee$ 6� Permit Fee S LDMA Ref."# o 0 7 1.7 5 4 v Lender's Address r ' 0 a 2 5 8 8 g I certify that I have read this application and state that theIssuance Fee (/, V LDMA P/C# 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. # and hereby authorize representatives of this County to enter upo t e above-meerty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signaturg of Appl cant or Agent Dafe