HomeMy Public PortalAbout9590 LOWER AZUSA RD_Building__ 5
WORKERS CQMPENSATION DECLARATION
hereby offir4 Ar that I have i erta of consent to self APPLICATION FOR BUILDING PERMIT
Insure or a certificate of Worr Compensation 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 APPLIC NT TO FILL IN BUILDING v t
ADDRESS
Certified copy is filed with thb county building inspec BUILDING
tion department ADDRESS
Date Applicant CITY i P1,E, LOCALITY t
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST ,
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO ASSESSOR
hundred dollars($100)or less ) TEL //� MAP BOOK PAGE MAP PARCEL
I certify that in the performance of the work for which this OWNER WJ?n � NO 4 7 USE ZONE NO
permit is issued I shall not employ any person in any manner ADDRESS �' C' SPECIAL
so as to become subject to the Workers Comp tion La CONDITIONS
Date ��� Z; ^�Apphcant CITY ZIP 8
ARCHITECT OR
NOTICE TO APPLICANT If afte making this Certifi o ENGINEER DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption you should become subject to the Workers ^ CONST+ / Zo�E V
Compensation provisions of the Labor Code you must forth Z V I
with complywith such provisions or this ADDRESS W
p permit shall be d'
deemed revoked TEL STATISTICAL CLASSIFICATION APT CO N
LICENSED CONTRACTORS DECLARATION CONTRACTOR NO Z7� Z
LIC CLASS NO DWELL UNITS
—
I hereby off irm that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP
(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 BK PG 31) VALIDATION
SQ FT NO OF NO OF CHECK
License Number Lic Class SIZE STORIES FAMILIES ONE
DESCRIPTION OF WORK A17— NEW Q VALUATION
Contractor Date )132
7 ,
1 am exempt under Sec ADD 0 $ A5
ALTER Qy 2
B&P C for this reason REPAIR = tqi� ✓.L
Dote USE OF DEMO"
EXISTING BLDG TEL
Signature APPLICANT
PRINTNO FINAL
OWNER BUILDER DECLARATION DATE
I hereby offirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 S Business and ADDRESS FIN
Prgfeesiona Code) B
I as owner of the property or my employees with AD DRESS ;181 la I A
wages as their sole compensation will do the work and # • • • • •t1
the structure Is not Intended or offered for sale(Section LOCALITY ' • 1 7 1 7 5
7044 Business and Professions Code) MOVING TEL • • 1 7 1 7 5 5
1 as owner of the property am exclusively contracting CONTRACTOR NO Q 2.3"8 7
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code) —481 8
REQUIRED TOTAL # • • • •
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pjtOp IINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT • • 6 31 7 5
the performance of the work for which this permit is issued PL ; Q23-87• • 63755
(Sec 3097 Civ C ) SIDE
Lender s Name P L ar
m I LDMA Ref ff
Lender s Address P C Fee E Permit Fee f r
I certify that I have read this application and state that the [ Issuance Fee t/ t� MA P/C i
g above information is correct I agree to comply with all County Invests g ation Fee
o ordinances and State laws relating to building construction Total Fee tDNA Perm N
o and hereby authorize representat s of this County to enter
I upon the above men oned prop for inspection purposes
m
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of App swnt Date