HomeMy Public PortalAbout9713 LOWER AZUSA RD_Building__ WORKERS'COMPENSATION DECLARATION s+
1 hereby affirm that 1 have cee of consent to self A P P L LCAT I O N FOR_ BUILDING PERMIT 1� '
insure, or a certificate of Workers'
Compensation Insurance, �,-,
or a certified copy thereof(Sec 3800, Lab C )) r
polr,CN.Z2777SdSll�ompany�ldf!K /(f cc _ - ' —'C U�T�Y OF LOS'ANGE�ES BUILDING AND SAFETY
Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING u
ADDRESS
(;Y"-eertified copy is filed with the county building ins - BUILDING
rv, h/on departrtmdnt G ADDRESS t `
Date / li�3� Applicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM RKERS' NO OF BLDGS 7 NEAREST C�
: COMPENSATION INSURA CE SIZE OF LOT NOW ON LOT
(This section need not be completed if the permit is for pne - ASSESSOR "
hundred dollars($100)or less ) TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL
I certifq that in the performance of the work for which this
OWNER
TEL USE ZONE Z _
Permit is issued, I shall not employ any person in any manner _ ADDRESS ` SPECIAL * - - O
so as to become subject to the WoKers'Compensation Laws CONDITIONS �r V
on IN'
Date' Applicant CITY ZIP - - �- O
NOTICE TO APPLICANT If, after making this Certificateof ARCHITECT TEL DISTRICT GROUP TYPE FIRE WBY
13
Exemption, you should become subject to the Workers' - ENGINEER NO COST� Z0-5 IW
Compensation provisions of the Labor Code, you must forth- ADDRESS i vU d.
with .comply with such provisions or this permit shall be = �-.
deemed revoked , TEL �/� STATISTICAL CLASSIFI TION APT DO
LICENSED CONTRACTORS DECLARATION CONTRACTOR-.O LNO !G{T�3 cLvss NO �- DWELL UNITS -'3
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS c NO 6 3 Z- R
(commencing with Section 700D)of Division 3 of the Business and a MAP
UC ,)
Professibns Code, and my license is in full force and effect CRY CLASSC ZC 2 BK PG I VALIDATION
SQ FT NO OF NO OF CHECK
License Number / L Lic Class SIZE STORIES FAMILIES ONE
_ VALUATION _
Contractor Date DESCRIPTION OF WORK _7) ea-7� AW $
I am exempt under Sec ALTER poll y
B&P C for this reason ! REPAIR
USE OF
Date EXISTING BLDG s/ to DEMOL
Signature - APPLICANT TEL FINAL
OWNER-BUILDER DECLARATION PRINT O DAT ' *387.7A
I hereby affirm that I am exempt from the.Contractor's License D //�
Law for the following reason (Section 7031 5, Business and ��S FI
T # e e e e e
Professions Code)- e '
BUILDING
I, as owner of the property, or my employees with ADDRESS * 06Q50'
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 e • * 6Q505-
1,
6Q505-1,as owner of the property,am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec- ADDRESS 01.20-86
hon 7044, Business and Professions Code)
SETBACK FROM
CONSTRUCTION LENDING AGENCY SET
REQUIRED-1YARD HWY TOT PROP LINE WIDTH J
I hereby affirm that there is a construction lending agency for FRONT
-the performance of the work for which this permit is issued PL - - --
(Sec 3D97, Cry C ) SIDE
PL
Lender's Name 6
,l LDMA Ref #
Lender's Address PC Fee$ Permit Fee !'a✓
I certify that I have read this application and state that the _ Issuance Fee V V V LDMA P/C# lop
above information is correct I agree to comply with all County Investigation Fee
ordinances and State laws latmg to building construction,
Total Fee LDMA Peim #
and he uthortze repr entatrves of this County to enter
upon t ab ve-menti n property for inspection purposes
SEB REVERSE FOR EXPLANATORY LANGUAGE v��
Stgnatur f Applicant or Agent Date