HomeMy Public PortalAbout10169 LOWER AZUSA RD_Building__ • ',, eWORKERS'COMPENSATION DECLARATION -
i insure,
?e olir 6 cer that`I haver certificate of consent to Self A P P L I CAT I.O N 1, FOR B U I L D G PERMIT
-I irisure, o'r a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company \
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDINGC
tion department. ADDRESS C 'E
Date Applicant CITY 'Y)p le Cf L ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' Vo B NO.OF BLDGS.O NEAREST
COMPENSATION INSURANCE SIZE OF LOT V U NOW ON LOT-fJ 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 I PAGE PARCEL
t TEL.GNIV --v USE NE MAP _2
I certify that in the performance of the work for which this OWNER b X � C S EIi NO. S, Z NO.
permit is issued, I shall not-employ,any person in any manner i I SPECIAL
ADDRESS Von CONDITIONS
so as to become subject to the Work r Compensa ion La ls. P�
- A d CITY / 6- ZIP
Date Applicant t `� ARCHITECT OR / I'' TEL. rG)
NOTICE TO APPLICANT: If, after making t is Cer ificate of ENGINEER `l3 ! vy�lh NO.��!/l L - DISTRICT G OUP TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers' c i( TYPE ZONE F—
P v I 5 , / U
Compensation provisions of the Labor Code, you must forth- ADDRESS Z� r7i� ' >� ` V W
with comply with such provisions or this permit shall be OL�
t TEL. �`) STATISTICAL CLASSI C TION APT. aNDO. rA
deemed revoked. CONTRACTOR�Ei 1� S�cur� . NO.0&"'/ �' /�/� Z
LICENSED CONTRACTORS DECLARATION \ !� LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1 b �f. �o. NO.
(commencing with Section 7000)of Division 3 of the Business and _ LIC. SEWER MAP/ '-c &-k—
Professions Code, and my license is in full force and effect. CITY A CLASS BK VALIDATION
SQ. FT. 2 NO. OF NO.OF' CHECK
License Number Lic.Class SIZESTORIES FAMILIES ONE
VALUATION
ContractorContractor Date DESCRIPTION OF WORK ADD ❑ $ O U
❑ I am exempt under Sec. ❑
/� ALTER �8 8 4 4 A
B.BP.C. for this reason /< R- REPAIR ❑ $
USE OF # 23
Date: EXISTING'BLDG.
DEMOL ❑ 0 0 0 0.
Signature APPLICANT p (� y\ TEL. J FINAL Io627,30
PRINT K&),
` V CANO. J
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS jyy�r FI °- 6 2 7.3,0 5
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT - B
BUILDING 0 1,25-88
❑ 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. -
1, as owner of the property, am exclusively contracting CONTRACTOR NO. ` l'
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CK FROM E
CONSTRUCTION LENDING AGENCY SREQUIRED
TT BACKK YARD HWY TOTAPROPALINE WIDTH �0 5 0.5 A
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 o748,50
Lender's Name
/► LDMA Ref. # ° ° 7 4 a 5 0
P.C. Fee$ JU Permit Fee �e V
Lender's Address / 0 &23-r88
$ 1 certify.that,l have react this application and state that the Issuance Fee ( 0e� LDMA-P/C k
above informotion 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
m up-n the above-mento ed_ r7o rty for inspection purposes.
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SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu a of Appl cant or Agent Dat