HomeMy Public PortalAbout9551 LOWER AZUSA RD_Building__ Imp-
•WORKEAS'CdMPENSATION DECLARATION
' I herby offApthdt I Have a certificate of consent to self APPLICATION FOR BUILDING PERMIT �
.
insure, or d
rt.f.ce of Workers Compensation Insurance,
or a certifitWcopy thereof(Sec 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy .s hereby+urniahed FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department ADDRESS
``AA � O
Date Applicant CITY Al C f I ZIP 1 LOCALITY412W7 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT ?i NOW ON LOT i CROSS ST
(This section need not be completed if the permit is for oneTRACT ��42 BL LOT NO ASSESSOR
hundred dollars ($100)or less ) MAP BOOK PAGE PARCEL
909(f/
TEL /� _ r USE ZONE MAP
I certify that in the performance of the work for which this OWNER r NO i� NO
permit is issued, 1 shall not employ any person in any manner [ TIM C, G r SPECIAL d
s0 as fo bec/o es b t to the Worke ensu Laws ADDRESS �+ CONDITIONS O
C CITY M �: ZIP 1 d v
Date— Applic
TEL
NOTICE TO APPLICANT If, after make fh er ficat ARCHITECT OR of ENGINEER A� DISTRICT GROUP TYPE FIRE PR SSED BY
Exemption, you should become subject to the Wo vers' ]p{ Q _ CONST / ZONE G
Compensation provisions of the Labor Code, you must forth- ADDRESS �'�" �l/J✓� ,Y/ d
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CO N
deemed revoked CONTRACTOR NO Z
LICENSED CONTRACTORS DECLARATIONLIC CLASS NO 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 andLIC SEWER MHP
Professions Code, and my license is in full force and effect CITY CLASS BK PG VALIDATION
SO FT NO OF NO OF CHECK
License Number Lic Class SIZE `Z STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORKQQ NEW ❑ J. Ot'
QDY1T AO�v"` ADD S U '
I am exempt under Sec
ALTER [:]
B 8P C for this reason REPAIR ❑ $
DateUSE OF
EXISTING BLDG IbV DEMOL E]
Signature APPLICANT r TEL /�� I FINAL
OWNER-BUILDER DECLARATION PRINT v 1\7 NO C DATE -2 8C7 �3 21.7 q
1 hereby affirm that I am exempt from the Contractor's License -T,G
Law for the following reason (Section 7031 5, Business and ADDRESS F L
Professions Code) WENT
#
BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and - 15300
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code) MOVING TEL • • 1 S 3 O O v
I, as owner of the property, am exclusively contracting CONTRACTOR NO '
with licensed contractors to construct the project (Sec- ADDRESS 0, 18-85
tion 7044, Business and Professions Code)
CK FROM EXIST
CONSTRUCTION LENDING AGENCY SETBACK YARD HWY TOTALPROP 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 10
PL
Lender's Name
P C Fee$ Permit fee D LDMA Ref #
Lender's Address {�)
I certify that I have read this application and state that the Issuance Fee oi`� �/ LDMA P/C#
above information is correct I agree to comply with all County
Investigation Fee
g ordinances and tate lowspolating to building construction, Total Fee (/ LDMA Perm #
u and hereby 90home r p sentatrves of this County to enter
9 upon the ve-rren property for inspection purposes F
a �� SEE REVERSE FOR EXPLANATORY LANGUAGE
O
gnaturebf .cant or nt Date °