HomeMy Public PortalAbout9923 LOWER AZUSA RD_Building__ • WORKERS'COMPENSATION DECLARATION
4 hove a certificate of consent to s
insube bbraffirm a certif carte of Workers'Compensation Insurancef APPLICATION FOR BUILDING PERMIT
ora certified copy thereof (Sec. 3800, Lab. C.)
Policy No.1XI1415Rt 1 Company 94&- C-1149246" /4��y COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS BUILDING
11 Certified copy is filed with the county building inspec- BUILDING
tion department. •��r�Le ADDRESS / / G / A RD
Dote 4'27 9 Applicant 1Z- . 1 1 1 V tf.ML CITY Cid ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' Nd OF BIDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one r ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT N MAP BOOK PAGE PARCEL
�L. USE NE MAP
I certify that in the performance of the work for which this OWNER �� NO. — NO —
permit is issued, I shall not employ any person in any manner �� USE
CIAL t
so as to become subject to the Workers'Compensation Laws. ADDRESS 41 //__ CONDITIONS C),
CITY Date Applicant ARCHITECT O /� ZIP I ( 77{D I•
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER �� i DISTRICT GROUP TYPE FIRE SSE BY 0
Exemption, you should become subject to the Workers' �^Md msY CONST. ZONE I--'
Compensation provisions of the Labor Code, you must forth- �J,—o ' ✓ 3 W
with comply with such provisions or this permit shall be ADDRESS TEL. STATISTICAL CLASSIFICATION APT. I CONDO Cn
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO._LL DWELL. UNITS Z
I hereby affirm 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 mmyy,license
1 is in full force and effect. CITY CLASS
Z CLASS BK / PG VALIDATION
HECK
License Number
�'���% Lic.Class
SQ.
ZEoVn 3 STORE FAMILIES I CONE
NEW VALUATION 6 D ;2p 7 5 6 A
Contractor_1A1 Qf r'.�.r- Date ' DESCRIPTION OF WORK =
I am exempt under Sec. - / AM , # • • • • 3
�+ Q ALTER
B.BP.C. for this reason N(t� "W141 9)k2 / PAIR s 1 • 51 Q 0 7
USE OF
Date: EXISTING BLDG D of , • ; 5 1'Q 0 7 c=s
Signature APPLICANT y— 4e f� TEL. FINAL (/
OWNER-BUILDER DECLARATION PRINT G� N NO. DAT
09.23-88
1 hereby affirm that I am exempt from the Contractor's License 7/%Ghis ���
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Q
Professions Code): By ( L'!//
BUILDING
El 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 , A. ' 1
7044, Business and Professions Code). MOVING TEL. 'AC
I, as owner of the property,am exclusively contracting CONTRACTOR NO. M4�T.r
with licensed contractors to construct the project (Sec- ADDRESS j07 9b9.01
tion 7044, Business and Professions Code).
CK FROMM
CONSTRUCTION LENDING AGENCY SET
REQUIREDB,ACK YARD HWY TOM PSETBROP. LINE WIDTH 1 ITQ1S
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. TOTAL 969.01
(Sec. 3097, Civ. C.). SIDE 969.01
Lender's Name LDMA Ref. # ME ,00
Lender's Address P.C. Fee$ 15_/01 01 Permit Fee
I certify that 1 have read this application and state that the Issuance Fee 00 ..P/C# pop.
above information is correct. I agree to comply with all County Investigation Fee 0000-OM1 4/23/90
ordinances and State laws relating to building construction, Total FeeW001 , ol LDMA Perm. #
and hereby authorize representatives of this County to enter 0242 1 AM 9.3`
upon the above-mentioned property for inspection purposes.
m
+23-W_ M REVERIE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date