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Home My Public Portal About9324 LOWER AZUSA RD_Building__ �6 WORKERS' COMPENSATION DECLARATION - I insusu reby affirm that I have re, or a certificate of Workers' certificate of consent to self kers' Compensation Insurance, APPLICATION F®R BUILDING P E RM I T or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company „ BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT 19 FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS LAA C� Date Applicant CITY up—oil-7gCJ LOCALITY NO. OF MUGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR p-�/ (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK D �o PAGE PARCEL 9 hundred dollars ($100)or less.) ® Q TEL. OWNER � T4)AS �. NO, USE ZONE MAP I certify that in the performance of the work for which this _ / NO. SPECIAL >_ permit is issued, I shall not employ any person in any manner ADDRESS Q law,N CONDITIONS a- so as to become subject to the Workers'Compensation Laws. +� Q CITY 1 �01�1`Q+ ZIP 13 V Date Applicant ARCHITECT OR TEL. W NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO DISTRICT GROUP CTMOPNST. ZONE PROCESSED BY O Exemption, you should become subject to the Workers' ti Compensation provisions of the Labor Code, you must forth- ADDRESS CL with comply with such provisions or this permit shall be TEL C y STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR N 3 0� _ LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 7,2L DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and m license is in full force and effect. CITY CLASS _t - Y t BK. PG. VALIDATION SIZE� � STORINO IEES ( FAMLIES ONE License Number Lic. Class VALUATION 4. ` Contractor Date DESCRIPTION OF WORK NEW ❑ $'32 C�= ❑I am exempt under Sec. 6WAIaT ADD ❑ 11011111. B.BP.C. for this reason ALTER $ REPAIR ❑ Date: USE OF hAN-1: °_- EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL, OWNER-BUILDER DECLARATION (PRINT) NO. FINAL o2��` I°i-I:-._`11 i-; ` . I hereby affirm that I am exempt from the Contractor's License DATE a:•., Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT ByBUIL - ❑ I, as owner of the property, or m employees with = { P P Y- YADDRIESS wages as their sole compensation,will do the work and ' the structure is not intended or offered for sale(Section LOCALITY loo. 7044 Bu iness and Professions Code.) MOVING TEL. V _ I,as r o.the property,am exclusively contracting CONTRACTOR NO. I j_ .� with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) /t• 1l� _•rte ___° REQUIRED TOTAL SETBACK FROM EXIST. 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 _I�. Lender's Name LDMA Ref. # + P.C. Fee$ , �O'D Permit Fee "/ O(O �� Lender's Address Al0 1 certify that I have read this application and state that the Issuance Fee A K LDMA P/C# )an ve infor 'on is correct. I agree to comply with all County Investigation Fee nances State laws relatingto building construction, 9 Total Fee / /' D LDMA Perm. # a hereby au ze representatives of this County to enter a bov mentjgned property for inspectio �purrp ses. O SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date PLICATI N FOR BUILDING PERMIT � COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILJL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUIL NG DDR or a certificate of Workers'Compensation Insurance,o e certified CITY ZIP copy thereof(Sec.3800.Lab.C. �p� _ a r.-- LOCALITYr. Llt Policy N ompany SIZ LOT f NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. 02 �� e'X 6l6 r '•-'� NEAREST CROSS ST. Id ertified cop is filed with the county building Inspection TRACT BLOCK LOT NO. epart nt. U�SyE�ZONE MAP NO. Applicant ASSESSg!5 BOOK PAGE PARCEL -sem+' Ar�c� � °� SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' � ��. TEL NO� � � YES N COMPENSATION INSURANCE WITHIN 1000 FT OF S HooL7 ADDRESS (This section need not be completed if the permit is for one hundred DISTRICT TYPE CONST.' FIRE ZONE PT�EDBY dollars($hat or less.) 2C z I certifythat in the performance of the work for which this permit is issued, I*shall not employ any person in any manner so as to ARCHITECT OR ENGINEER become subject to the Workers'Compensation Laws. ! 2 STATISTICAL CLASSIFICATION APT CONDO Date Applicant Ann CLASS NO. 0!!"e DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' ?DRESS O �_ TEL.NO. SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith N FRONT comply with such provisions or this permit shall be deemed revoked. L NO PL SIDE 97 >` LICENSED CONTRACTORS DECLARATION LI LASS PL 83. o I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP I IL's'I a V v NO.OF STORES NO. FAMILIES (commencing with Section 7000)of Division 3 of the Business and �•FT SI Professions Code,an s II force an NEW BK PG ® 3307 11?.-I r v `\ DESCRIPTION OF WORK ADD ❑ TI �jj. Tf License Numbe ic.Class / Q� LU Contractor Date ALTER ❑ 2 GtJ dS'bf o �1�1TAL �#.��o�`� ❑ I am exempt under Sec. 2 REPAIR ❑ CHECK 1196.59 B.BP.C.for this reason /3L'oar• DEMOL ❑ LDMAP/C# CHANGE .0111 Date. USE OF EXISTING BLDG. URM ❑ Signature AP CANT(PRI TEL N LDMA Penn M 00,1313-ljj�l3 1 6/18/90 ❑ 1, as owner of the property, or my employees with wages as 9 aO � r- their sole compensation,will do the work and the structure is A a 1330 1 A 10o o��' not intended or offered for sale (Section 7044, Business and FINAL DATE C Professions Code.) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANTHANDLEA HAZARDOUS MATERIAL ' 7 — J ❑ 1, as owner of theproperty, am exclusively contracting with THE A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO TI GREATER THAN l ) g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FlNALy 1 licensed contractors to construct the project (Section 7044, YES j] NO 11 Business and Professions Code.) WILL THE INTENDED USE THE BUILDING BY THE APPLICANT OR FUTURE BUILDING n OCCUPANT REQUIRE PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH jr)/ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST V FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NO❑ the performance of the work for which this permit is Issued(Sec. ;' '• r r ---i t`I 3097,CIV.C.. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD Cr, C-1 [,I PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES r: �� Z, iTl •••• '•�' COUNTY CODE.TITLEZ CHAPTER 220 SECTIONS 220.100THROUGH 270.140 CONCERNING Cr' r,"•, :' 7:.^ LendeYs Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. r Lender's Address ,a OWNER oxAGENT r-,;.� •- i 0 mop ad t is application and state that the above r I agree o comply with all county P.C.FEE c �.o PERMIT FEE 6� „I to I relat to building construction,and rep sentat' of this County to enter po ISSUANCE FEE e rope or inspection purposes / '-n D INVESTIGATION FEE 4`- 1',1 TOTAL FEE f �i a r-•• -� e e' / a Onto • ••~! 1`.f 1=•, 1"-, SEE REVERSE FOR EXPLANATORY LANGUAGE I WORKERS'COMPENSATION DECLARATION - • re ra that i have certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, APPLICATION F OR BUILDING P E RM I T or a certified copy thereof(Sec. 3800, La .) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N� CompanyU BUILDING ❑ Certified copy is hereby furnished. �� FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- ADDRESS �'- ,[ 1� 7-�� 1 tion department. .1 � CITY C fZIP LOCALITYDate 1/-173 f Applicant � NCY OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. AVE COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one .TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL �'y hundred dollars ($100)or less.) TEL. OWNER Q,6.,d C)emm6— NO, USE ZONE MAP 1 certify that in the performance of the work for which thisSPE SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS 9 a- � y- '`.;� CONDITIONS n- so as to become subject to the Workers'Compensation Laws. OO clrr ZIP Date Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIREkPROCESSEDB_Y CONST. ZONE Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS +pe with comply with such provisions or this permit shall be /� (� ,, TEL.9 $s STATISTICAL CLAS SI O APT. ' deemed revoked. CONTRACTOR `� M �9 +"Il NO. )r �O1_CqNl)q. Z LICENSED CONTRACTORS DECLARATION ` - ' LIC. CLASS NO. DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS S fl)W' NO. 4Oq3 7 (commencing with Section 7000)of Division 3 of the Business LIC. _L� SEWER MAP _F .t CITY i!`" CLASS ! and Professions Code,and my license is in full force and effect. BK. PG. _ !�7!AIDATION t, � ��.---- SQ. FT. NO. OF NO. OF CHECK )�11 License Number �T 2 pc. Classq� SIZE I STORIES FAMILIES ONErl C VALUATION -!.fu + Contractor m, � Date j 17,2r_ DESCRIPTION OF WORK NEW ❑ y.. ,a rJ 11n! ^� ❑ ADD ❑ . / , f v ® _ - I am exempt under Sec. ALTER ❑ b $ � I• B.&P.C. for this reason d/ 'USE OF REPAIR ❑ L EXISTING BLDG. -- , DEMOL ❑ '. vJignature-xF� e..3.+^ .e APPLICANT T) �,� 't1 - _ eA s FINAL IJWNER-BUILDER DECLARATION DATE "'ZL ••- I hereby affirm that I am exempt from the Contractor's License V'1� �F?� A Law for the following reason (Section 7031.5, Business and a ADDRESS 3 9 0 1 FINAL Professions Code : PRESENT B BUILDING I„ y ❑ 1, 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. ❑ h 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.) REQUIRED TOTAL SETBACK FROM JEX CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE ` I hereby affirm that there is a construction lending agency for FRONT �I= L}. the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE -P.L. -•}":_�. --Lender's Name Name $ LDMA Ref. #P.C. Fee$ Permit FeeLender's Address . - ---I certify that I have read this application and state that the t: Issuance Fee LDMA P/C# ,_ labove information is correct. I agree to comply with all County Investigation Fee _ordinances and State laws relating to building construction, "' Total Fee /+ LDMA Perm. # _=L+''' = and hereby authorize representatives of this County to enter ukvthe .bove-mentioned property for inspection purposes. o Q — •2 1 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date