HomeMy Public PortalAbout9927 LOWER AZUSA RD_Building__ WORKERS'COMPENSATION DECLARATION
hereby affirm that hovecertificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificatee of Workers'Compensationion Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Companyj
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN Gk�! BUILDING
ADDRESS
Certified copy is filed with the county building inspec- BUILDING � R�
tion department. ADDRESS
Date ApplicontF- 111L1L*K_J CITY G� ZIP 0 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' ( CROSS
OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT 21?f NOW ON LOT CRS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK L T N MAP BOOK I PAGE PARCEL
OWNE 1. USE ZQNE
I certify that in the performance of the work for which this - 404V-
'� „rC//I— MA
permit is Issued, I shall not employ any person in any manner ADDRESS O `T. �U/v , r CONDITIONS ,
SPECIAL
so as to become subject to the Workers'Compensation Laws. U
Date b Applicant R--[LTu CITY
NOTICE TO APPLICANT: If, offer making this Certificate of ARCHITECT — DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers' ENGINEER � )k_
CONST. ZJ�1NE U
Compensation provisions of the Labor Code, you must forth- ADDRESS K
with comply with such provisions or this permit shall be 1EL183NDO. s+-
deemed revoked. CONTRACTOR NO. STATISTICAL IFI TION APT. Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS/
I hereby affirm that 1 am licensed under provisions of Chapter 9 ADDRESS NO. SEWER NAP
(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 VALIDATION
SQ. OF NO.OF CHECK
License Number Lic.Class SIZE 3 STORIES oC FAMILIES ONE
` ' VALUAT ON
Contractor�"�( CmtgT(3lC1 to — DESCRIPTION OF WORK NEW $ /�A3'�I
I am exempt under Sec. lL v LTER a l/ / , 0 7 5 4 A
B.BP.C. for this reason a REPAIR $ # • • • • 2 3
USE '
Date: EXISTING BLDG. OL I • 5 t$O 7
Signature APPLICANT
TEL. _ FINAL
OWNER-BUILDER DECLARATION
(PRINT) NO. DATE �'ZY�� • • tj a 0 7 czt
1 hereby affirm that I am exempt from the Contractor's License Q�1/j �Q
Law for the following reason (Section 7031.5, Business and ADDRESS v i�`-� �
FINAL // .
Professions Code): By 0 9.2 38 8
1, as owner of the property, or m employees yBUILDING
with ADDRESS
wages as their sole compensation,will do the work and LOCALITY ,
the structure is not intended or offered for sole(Section 1
7044, Business and Professions Code). MOVING TEL. ACCT.T
I, as owner of the property,am exclusively contracting CONTRACTOR NO. ACCT
.A
licensed contractors to construct the project (Sec- ADDRESS W 969.01
tion 7044, Business and Professions Code).
CK FROM
CONSTRUCTION LENDING AGENCY SgACK YARD HWY TOTALP� LINE WIDTH 4 1 ITEMS
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L. TOTAL 969.01
(Sec. 3097, Civ. C.). SIDE
P.L. GECK 969.01
Lender's Name 5-10-0-7
"' �) CK*m
P.C. Fee$ �/ D- Permit Fee D LDMA Ref. N W 7� •�
Lender's Address
I certify that I have read this application and state that the Issuance Fee DO LDMA P/C N L nWf
above Information is correct. 1 agree to comply with all County Investigation Fee w-0001 4/23/9t1
ordinances and State laws relating to building construction, Total Fee LDMA Perm. N •''�
and hereby authorize representatives of this County to enter 0244 1 AM 9.35
upon the above-mentioned property for Inspection purposes.
��'rp j/y``� •'L�j' 1 D SO REVERU FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date