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Home My Public Portal About9925 LOWER AZUSA RD_Building__ WORKERS' COMPENSATION DECLARATION / hereby affirm that I have r certificate of consent to self P P L I CATION FOR BUILDING PERMIT insure, or a certificate of Workers: 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 APPLIC6NT TO FILL IN CRESS a5 Certified copy is filed with the county building inspec- BUI ING tion department. - AD RESS Date Applicant ITY' ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT OF BLDGS. NEAREST, COMPENSATION INSURANCES NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one TRACT BLOCK ASSESSOR LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL. OWNER / NO. USE ZONE OP I certify that in the performance of w k for which this permit is issued, I shall not employ ny pe n in manner ADDRESS �'. SPECIAL a CONDITIONS so as to bec a subject to the rkers' om a ation Laws. O le; CITY ZIP V Date Ce App�ca ARCHITECT ORTEL, I \TCEWD BY 0' NOTIC TO APPLICANT: Ir mak g this.Certifi ate of-, ENGINEER NO: DISTRICT GROUP TYPE FIREExem tion, g/ CONS .p you shouldme subject to the Workers' `J (/xCompensation provisions e tabor Code,'You must forth- ADDRESS Wa with comply with such provisions or this ATISTICAL CLASSIFICATION APT. CONDO, v7 p y p permit shall be ��yy �� TEL. Z deemed revoked. CONTRACTOR �`f�C - NO. — _ LICENSED CONTRACTORS DECLARATIONUC. CLASS NO. DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9' ADDRESS NO. t/ (commencing with SectionLIC.of Division 3 of the Business LIC• SEWER MAP and Professions Code,and my license is in full force and effect. CITY a� CLASS BK PG VALIDATION SQ. FT. NO. OF NO.OF CHECK License Number Lic. Class SIZE STORIES FAMILIES ONE O NEW ❑ VALUATION Contractor Date DESC ION OF WORK $ El am exempt under Sec. � ADD El 00ALTER .❑ B.P.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TE OWNER-BUILDER DECLARATION (PRINT) QFINAL I hereby affirm that I am exempt from the Contractor's License /, DATI Walt E,. 1 Low for the following reason (Section 7031'.5, Business and ADDRESS /l l / FINAL Professions Code): SENT By - ACGT•ir ElI, as owner of the ro a BUILDING p p rty, or my employees with ADDRESS_. 3117 �i pV• . wages as their sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section Poll. ITEMS - 7044, Business and Professions Code.) MOVING TEL. 60'.50 El 1, as owner of the property,am exclusively contracting CONTRACTOR NO. TOTAL with licensed contractors to construct the project (Sec- ADDRESS 60.50tion 7044, Business and Professions Code.) REQUIRED. OTAL SETBACK FROM EXIST. -0111 CONSTRUCTION LENDINGAGENCY SET BACK YARD HWY PROP. LINE , 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. (Sec. 3097, Civ. C.'). SIDE. . PA.' Old-Ml 10/23/89 Lender's Name' LDMA Ref. # • Lender's Addr P.C. Fee$ Permit Fee OJJV 1 �it11•1L 1 certify t t I ave read this application and state that the Issuance Fee LDMA P/C# Lender's i arm ion is correct. /a ee To comply with all County Investigation Fee r,�i ordin ces d State la re at to bui ing construction, Total Fee /✓ LDMA Perm. # and ereb authorizer res tatives of is County.to enter' up th above party for ns action purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature o Applicant or Agan Date WORKERS'COMPENSATION DECLARATION to s InsJre"6r a ertif cote of Workers' Compensat onthat �have a certificate ofbent Insuran e, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, lab. C.) �q � COUNTY OF LOS ANGELES BUILDING AND SAFETY P91icy NO.U `sAl company �1, 10 Q Certified copy is hereby furnished. FOR APPLICANT TO FILL I BUILDING ADDRESS Certified copy is filed with the county building inspec- fADDRESS LDING ♦l 2 .fir, tion department, p �{ I I n, fDate aO Applicant 1 - 1rru�-If 1_' �i��[` ZIP LO A.ITV CERTIFICATE OF EXEMPTION FROM WORKERS' I NO.OF BLDGS• NEAREST r COMPENSATION INSURANCE SIZE OF LOT O NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) TRACT BLOCK LOT NQe P BOOK PAGE PARCEL L' USE! NE I certify that in the performance of the work for which this OWNER NO. permit is issued, I shall not employ any person in any manner ADDRESS �� .!/ IAL so as to become subject to the Workers'Compensation Laws. c p CONDITIONS CITY ZIP / Dote Applicant ARCHITECT O NOTICE TO APPLICANT: If, after making this Certificate of G✓ DISTRICT UP TYPE FIRE SSED BY O ENGINEER Exemption, you should become subject to the Workers- �'' /1 CONS / Z W Compensation provisions of the Labor Code, you must forth- ADDRESS J V (/ with comply with such provisions or this permit shall be deemed revoked. CONTRACTOR NO STATISTICAL CLASSIFICATION APT. VbNDO. N LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS-"--_L__ Z I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASSVALIDATION S0. NO.OF NO.OF CHECK BK. PG.� License NumberZ Lic.Class SIZ STORIES FAMILIESONE VALUATIONIry 0 7`a 5 A Tia DESCRIPTION OF WORK f� Conhactot�'1 1.1 C.D ip 1�TV^ to � �� = 2 3 # . . . . 2 3 I am exempt under Sec. DD fi ALTER ❑ , 1 • 51 Q 0 7 B.BP.C. for this reason r D REPAIR = * 951Q0750 Dote: U EXISTING BLDG. DWL Signature APPLICANT /n1 TEL. //i- 0 9,2 3-'$8 OWNER-BUILDER DECLARATION PRINT /4140. FINAL Co Z 6 I hereby affirm that 1 am exempt from the Contractor's License a DATE Low for the following reason (Section 7031.5, Business and ADDRESS� RNAL Professions Code): BT 1 BUILDING 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ' i ''ACCT•i the structure is not Intended or offered for sale(Section LOCALITY � �Le•r1 7044, Business and Professions Code). MOVING TEL. M0 o7 V1 I, as owner of the property, CONTRACTOR NO. , i T p party, am exclusively contracting1 1 with licensed contractors to construct the project (Sec- ADDRESS TOTAL 969.01 to44 n 70 , Business and Professions Code). MOMMMr , CONSTRUCTION LENDING AGENCY SET BACK YARD HWYTOTALROP. LINE WIDTSETBACK FROM H ( �( 969.01 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. (Sec. 3097, Civ. C.). SIDE cwma .([1 P.L. Lender's Name /O /) I LDMA Ref. aY MlN1_11M1 4/23/90 Lender's Address P.C. Fee= V Permit Fee ' W�J1.JR�JJJ TT LJJ 77 VV I certify that I have read this application and state that the Issuance Fee LDMA P/C M 0243 1 AM 9=35 g above information is correct. I agree to comply with all County Investlgotion Fee $ ordinances and State laws relating to building construction, Total Fee 'R and hereby authorize representatives of this County to enter 1 LDMA Perm. M upon the above-mentioned property for inspection purposes. m HQ > '23 (J SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date