The URL can be used to link to this page

Home My Public Portal About9578 LOWER AZUSA RD_Building__ WORKERS COMPENSATION DECLARATION 4110 hVe* airm thatinsure orafcertificatejofWorkeseCohave a impenstfonInsurance cate oconsent to o'r APPLICATION FOR ILDING PERMIT a certified copy thereof(Sec 3800 lab C ) \ COUNTY OF LOS ANGELE _ ► BUILDING AND SAFETY Policy No Company `\] BUILDING Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec BUILDING tion department \ ADDRESS LOCALITY .VI NEAREST Date Applicant CITY ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LOT OW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars($100)or less ) TRACT BLOCK LOT NO NO Z'07�1 TEL SPECIAL d I certify that in the performance of the work for which this OWNER CONDITIONS 0 permit is issued I shall not employ any per on in any manner DISTRICT GROUP TYPE FIRE D BY V ADDRESS 09 so as to becom e subject to the Work r m ensa o aws h' .O� N ' / NE Date&O" " 2 pplicant CITY&w�� D�c�D WAP 12 V STATISTICAL CLASSIFICATION If/ APT CONDO �j NOTICE TO APPLICANT If after making this Certificate of ENGIARCHNEER OR J NO CLASS NODWELL UNITS Exemption you should become subject to the Workersy Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP a with comply with such provisions or this permit shall be TEL deemed revoked CONTRACTOR ~ NO SK PG VALIDATION LICENSED CONTRACTORS DECLARATION UC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC Professions Code and my license is in full force and effect CITY CLASS $ SQ FT NO OF NO OF CHECK License Number Lic Class SIZE STORIES FAMILIES ONE DESCRIPTION 6F WORK T� NEW $ ❑ Contractor Date ❑ ❑ I am exempt from The licensing requirements as I am a ADD licensed architect or a registered professional engineer ALTER ❑ DATE.2 _ ✓ acting in my professional capacity (Section 7051 REPAIR ❑ Business and Professions Code) USE OF DEMOL FINAL u EXISTING BLDG ❑ By � � ,a �� Lic or Reg N6 Date APPLICANT TEL OWNER BUILDER DECLARATION PRINT NO I hereby affirm that I am exempt from the Contractor s license Law for the following reason (Section 7031 5 Business and ADDRESS Professions Code) PRtbtml r� BUILDING u I as owner of the property or my employees with ADDRESS wages as their sole compensation will do the work and ;@1 6 9 7 A the structure is not intended or offered for sale(Section LOCALITY 7044 Business and Professions Code) MOVING TEL # • • • • • 1 1 as owner of the property am exclusively contracting CONTRACTOR NO 2 2 with licensed contractors to construct the project (Sec tion 7044 Business and Professions Code) ADDRESS • • REQUIRED TOTAL SETBACK FROM EXIST • • • 2 5 Q Q F2 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH I hereby off irm that there is a construction lending agency for FRONT 027-81 the performance of the work for which this permit is issued P L (Sec 3097 Civ C ) SIDE PL Lender s Name \ Lender s Address PC Fee$ Permit Fee W I certify that I have read this application and state that the Issuance Fee '— above information is correct I agree,to comply with all County Inv6stigation Fee ordinances and State laws relating to building construction Total Fee and her authorize pre f t i unty to enter upon the a on p pert)& r on purposes _ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dote ®s • 'WCkKERS COMPENSATION DECLARATION • I herebirrn certificate that I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T ifi'sure or�certificate of Workers Compensation Insurance FOR, , BUILDING 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 g�ILDING SA- ❑ Certified copy is filed with the county budding tnspec BUILDING tion department ADDRESS US P- Date Applicant _• CI /, /No ozip BLDGS LOCALITY CERTIFICATE OF D(EMPTION FROM WORKERS SIZE OF LOT S 6 NOW ON LOT NC O55 ST U ty COMPENSATION INSURANCE A�� (This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL hundred dollars ($100)or less) TEL OWNER NO - USE ZONE MAP I certify that in the performance of the work for which this /� Al{, o /�permit is issued I shall not employ any person in any manner ADDRESS 67 !\ /a Ua' /" ONDITIONS O so as to become subject to the Workers Compensation Laws CITY 41 ha,,bcqZIP q4 0a- V Date—Applicant ARCHITECT OR TEL DISTRICT 7GROUP TYPE FI 0 NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO CONST IM- Exemption BY Q Exemption you should become subject to the Workers �v04k Compensation provisions of the Labor Code you must forth ADDRESS /� O �/ with comply with such provisions or this permit shall be CONTRACTOR owG�1l.Qil� NO STATISTICAL CLASSIFICATION CONDO 7 ' deemed revoked d.� LICENSED CONTRACTORS DECLARATION UC CLASS NO 0a DWELL UNITS - 1 hereby affirm that I am licensed under provisions of Chapter9 °ODS NO LIC SEWER MAP }I��AL �, (commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is to full force and effect CITY CLASS BK I��1Ft�1LIDATION 1.� SQ FT NO OF NO OF CHECK Cha i License Number 4c Class SIZE STORIES FAMIUES ONE VALUATION T�F43E J30Contractor Date DESCRIPTION OF WORK ANDD El too El am exempt under Sec t !J ► 0001-0001 lif:7/ L ALTER B 8P C for this reason REPAIR ❑ $ f�'" � 1AM '-r1.1 Date USE of MAOI EXISTING BLDG &/}/S/� Signature APP(PRINT) NO CANT TEL FINAL 6- -5-41) OWNER BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor s License ADDRESS FINAL i Law for the following reason (Section 7031 5 Business andZ(A Professions Code) PRESENT BYs a ElBUILDING 1 as owner of the property or my employees with ADDRESS , wages as their sole compensation will do the work and LOCALITY �,..�d 1 e r?9 the structure is not intended or offered for sale(Section L� 7044 Business and Professions Code) MOVING TEL i it Ela I as owner of the property am exclusively contracting CONTRACTOR NO TI ITAL 109® + with licensed contractors to construct the project (Sec ADDRESS tion 7044 Business and Professions Code) {KCK 109 57 CONSTRUCTION LENDING AGENCY SET s�D YARD HwY TOTALR PL LINE FROM EXIST r i� rte- I I hereby affirm that there is a construction lending agency for FRONT K a 01 the performance of the work for which this permit is issued PL (Sec 3097 Civ C) SIDE Lender s Name P L LOW-0001 SMA Ref # In-68 PC Fee Permit Fee Lender s Address Lt 10. I certify that I have read this application and state that the Issuance Fee LDMA P/C# above information is correct I agree to comply with all County Investigation Fee r ordinances and State laws relating to budding construction Total Fee i J LDMA Perm and hereby a thorize epresentativea of this County to enter upon thea a me property for inspectZo /pur sea O Z- SEE REVERSE FOR EXPLANATORY LANGUAGE Sig tum of Applicant or Agent Dat