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Home My Public Portal About9933 LOWER AZUSA RD_Building__ WORKERS',COMPENSATION DECLARATION nt to self insurebora.cetliotteoffWorkers'Compensatohave a certificate of nInsurane, APPLICATION FOR BUILDING PERMIT or o certified copy thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No — Company LUg(Cr BUILDING C ified copy is hereby furnished MMOM V FOR APPLICANT TO FILL IN ADDRESSAl ADDRESS ...J Certified copy is Bled with the county building inspec- BUILDIPTG tion department ADDRESS4ftfz '' Dote'4119 Applicant - '(1Tlll.Alei CITY zip / LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS NEAREST r COMPENSATION INSURANCE SIZE OF LOT JZ <40tl NOW ON LOT CROSS ST (This section need not be completed if the permit Is for oneASSESSOR hundred dollars($100)or less) TRA BLOCK L NO MAP BOO( PAGE PARCEL, LUSE NE _ I certify that In the performance of the work for which this OWNER P }. permit is Issued, I shall not employ any person in any manner ADDRESS �� ' SPECIAL iL so as to become subject to the Workers'Compensation Laws CONDITIONS 8 Date 4=_-"_—J(2 Applicant t- -TITUaT?-- GTY �i� ZIP CO 0: NOTICE TO APPLICANT If, after making this Certificate of ARCH 015TRICT GROUP TYPE FIRE BY O Exemption, you should become subject to the Workers' /1 MT/ ZONE Compensation provisions of the Labor Code, you must forth- ADD with comply with such provisions or this permit shall be TEL STATISTICAL I(3ATION APT NDO Z deemed revoked CONTRACTOR NO LICENSED CONTRACTORS DECLARATION LIC CLASS NOIf DWELL UNITS I hereby offirm 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 to full force and effect CITY CLASS % VALIDATION BK L PG Stam FA of ` cOEa vAlue►n ;90757A License Number ,, 1� Uc Class F IUEs ONE Contractor4��rUC 2( ate DESCRIPTION OF WORK NEW $ V poll- # • • • • 23 R I am exempt under Sec J` � 1 * 523,46 TE B&P C for this reason10 1 REPAIR = - 9523,465 r Data U OF EXISTING BLDG 0 9.'2 3 y 8"8 Signature APPLICANT TEL flNAI 7_/ j OWNER-BUILDER DECLARATION IF NO DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Business and ADDRESS 41t RNA .Q Professions Code) By 1, as owner of the property, or my employees with ADBUILDINGDRESS wages os their sole compensation,will do the work and �CT•# the structure is not intended or offered for sole(Section LOCALITY , 3M7 996.64 7044, Business and Professions Code) MOVING TEL .]J�� rt�s� I,as owner of the property,am exclusively contracting CONTRACTOR NO 1 I 1 GI h7 with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code) i4DORE� TOTAL 996.64 IR CONSTRUCTION LENDING AGENCY BA YARD HWY TOTAL PROP LINE WIDTH ( 996 1 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 PL Lender's Name ry LDMA Ref 0 i 4/23/90 $ Lender's Address P C Fest r Permit Fee3o64 , t I certify that I have read this application and state that the Issuance Fee LDMA P/C tl 0247 1 All 9:36 g above Information is correct I agree to comply with all County Investigation Fes ordinances and State laws relating to building construction, Total Fee LDMA perm N and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes 'T•U-410 SH REVBRff FOR EXPLANATORY LANQUAGE Signature of Applicant or Agent Dote