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Home My Public Portal About9584 LOWER AZUSA RD_Building__ (2) WORKERS COMPENSATION DECLARATION a, hereby affirm that I have a certificate of consent to self , APPLICATION F O�(!P- I L D I N G PERMIT � insure or a certificate of Workers Compenstion Insurance or a cert ie eco,It 7 COUNTY OF LOS ANGE BUILDING AND SAFETY Po 4 Certified copy is hereby furnished �„� FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is filed with the count buil ing inspec BUILDINGQ c` ,1 n tion department ADDRESS%�� 'ok 2415 �� LOCALITY ' Date Applicant CITY �l-,F Ld17jP NEAREST pp /^ ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSOR ' COMPENSATION INSURANCE SITE OF LOT NOW ON LOT MAP BOOK PAGE RCEL (This section need not be completed if the permit is for one USE ZONE MAP 0 hundred dollars ($100)or less ) TRACT BLOCK LOT NO NO I certify that in the performance of the work for which this OWNEPSR911S N4 �j y,� IAL � 7 I NS Q permit is issued I shall not employ any person in any manner ��//�1 a �j DISTRICT FIRE SSED BY ` to so as to become subject to the Workers Compensation Laws ADDRRE7SS 7&V Off /L //QA� CON T Z NE CITYG/*RO/I//� 3/�Z /rl ZIP Date Applicant STATISTICAL cLAswKGATION APT CONDO NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TELENGINEER NO IY Exemption, you should become subject to the Workers CLASS NO DWELL UNITS d Compensation provisions of the Labor Code you must forthwimmiiiiiiiiiiiiiiii N with comply with such provisions or this permit shall be ADDRESS u SEWER MAP ? deemed revoked CONTRA /r^ L Yl^ S �/r'/ TN — BK PG VALIDATION LICENSED CONTRACTORS DECLARATION n' LIC �+ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE T � njW /df 57 NO � �/d/� VALUATION ov (commencing with Sectio 7000)of Division 3 of the Business and CITY /S'��/e j� LIC / $ / Professions Code and m license is in full force and effect � SQ FT NO OF NO OF CHECK License Number Lic Class SIZE STORIES FAMILIES ONE ;90023A Contractor Date # es - 23 DESCRIPTION OF WORK L1 &6 NEW ❑ El �j am e4empt from the licensing requirements as I am a ADD 1,j ,�/��/f/ licensed architect or a registered professional engineer ALTER ❑ FINAL r7rlO mr� 2 • • 2 160 acting in y professional capacity (Section 7051 �d Y��l//oF L��Tjr' REPAIR DATE / V Business and Professions Code) USE OF ❑ FINAL • • • 2 16 0 c=� EXISTING BLDG DEMOL ❑ By Lic or Reg No Date APPLICANT TEL 0 622-81 OWNER BUILDER DECLARATION PRINT NO I hereby affirm that I am exempt from the Contractor s License t— Law for the following reason (Section 7031 5 Business and ADDRESS Professions Code) PRESENT BUILDING J 1 as owner of the property or my employees with ADDRESS 0 0 2 4 A wages as their sole compensation will do the work and the structure is not intended or offered fat sale(Section LADDRE �� # • • • • • 7044 Business and Professions Code) TEL ❑ 1 as owner of the property am exclusively contracting OR NO , .�� 2 • • 34.0 0 with licensed contractors to construct the project (Sec tion 7044 Business and Professions Code) t �/ �O/J// • • • 3 4,0 0 5 D TOTAL SETBACK FROM EXIST v� CONSTRUCTION LENDING AGENCY o YARD HWY PROP LINE WIDTH G22-8I hereby affirm that there is a construction lending agency for vl � /the performance of the work for which this permit is issued(Sec 3097 Civ C ) ��j�ALender s NameLender s Address �/ Permit Fee `7� W I certify that I have r d this application and state that the Issuance Fee above information is rrect I agree to comply with all County Investigation Fee ordinances and Stat laws relating to building construction Total Fee / and hereby a tho epres ntatrves of this County to enter U upon th ab ve a ned party for inspection purposes a SEE REVERSE FOR EXPLANATORY LANGUAGE ignatureof Ap t or Agent Date ®s r WORKERS COMPENSATION 6ECLARAION hereby affirm that I have a certificate of consent toself APPLICATION F O BUILDING PERMIT insure or a certificate of Workers Compenstion Insurancc e or a certified c p thereof(Sec 3800 Lab C ) � COUNTY OF LOS AN EL , BUILDING ANDS FETY Policy No7hTCompany Certified copy is hereby furnished 61� FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the ounty buil i g inspec BUILDING ti de ailment ADDRESS rill LOCALITY NEARES Date Y Applicant CITY r� ZIP CROSS ERTI CATE OF EXEMPTION OM WORKERS NO F BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP TRACT BLOCK LOT NO NO hundred dollars ($100)or less ) er TEL CIAL p, I certify that in the performance of the work for which this OWNER NO 1 [CONDITIONS Q TYPE permit is issued I shall not employ any person in any manner DIS T GROUP CONSTZ RE E OCE ED BY I (J so as to become subject to the Workers Compensation Laws ADDRESS O(/ _ C9 Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT JCONDO NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL Exemption you should become subject to the Workers ENGINEER NO CLASS NO�DWELL UNI TS N Compensation provisions of the Labor Code you must forth ADDRESSl/ SEWE P with comply with such provisions or this permit shall be �� TEL S J7 deemed revoked CONTRACTOR NO VALIDATION LICENSED CONTRACTORS DECLARATION rLIC G I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O 3 6f3/ VA ATION (commencing with Section 7000)of Division 3 of the Business pnd LIC �Z,G n Professions Code and my license is in full force a fect CITY �j CLASS l/ $ QA`d SQ FT 1 NO OF NO OF CHECK License Numbe b Lic Class SIZE �F STORIES FAMILIES ONE n_ NEW $ Contractor /� Date DESCRIPTION OF WORK ❑ o Ell a em xempt from the licensing require ents s I am a ADD 0 1 9 9 A licensed architect or a registered professional engineer ALTER ❑ FINAL acting in my professional capacity (Section 7051 REPAIR ❑ DATE e7r 10 �Q # 9 - 23 e e e 2 3 Business and Professions Code) USE OF ` f 1 FINAL /_ _ 2 • 1 1 5 2 Q EXISTING BLDG V /�1�1\ DEMOL ❑ By Lic or Re No Date APPLICANT TEL x Reg OWNER BUILDER DECLARATION PRINT Q NO �J�S e e l T S 2 O c' I hereby affirm that I am exempt from the Contractor s License ADDRESS t�S�g v V 0615-81 Law for the following reason (Section 7031 5 Business and Professions Code) BUILDING Lj 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 2 0 2 0 0 A I as owner of the property am exclusively contracting CONTRACTOR NO with licensed contractors to construct the project (Sec ADDRESS # • •10 • • 1 tion 7044 Business and Professions Code) REQUIRED TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH 2 • 15100 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 • e,1 51 006 (Sec 3097 Civ C ) RIDE 0615-81 Lender shame Lender s Address P C Fee$ L/ �O`� 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 Investigation Fee /� 9 ordinances and State jaws relating to building construction an hereby authors representatives of this County to enter Total Fee n the a ve moe 1 11 Boned property for inspection urp7ss Q SEE REVERSE FOR EXPLANATORY LANGUAGE a ^ ignature o pp scant or Agent ate s