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Home My Public Portal About10405 LOWER AZUSA RD_Miscellaneous__ i WORKERS'COMPENSATION DECLARATION CE 875 (11-84) M ISCELLANEOUS APPLICATION I I Hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING �D�D a ❑ ADDRESS Certified copy is hereby furnished. g BUILDING h '1 �f' OCA LITV / ADDRESS tV - (�. 10W PAZ 1112 1 ( 1 Certified copy is filed with the county building inspection % LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST �'+ �,� 01 STTRI, GR� TY 5� P ESSED BY CROSS ST. ` Q(/ i CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY ND. (clwce) STATE MAJOR SECOND LOCAL NO. OF BLDGS. l. (This section need not be completed If the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner X OWNER C A CAEI) NEW Q4 ® , so as to become subject to the Workers' Compensation Laws. g ^ OCCUPANCY GROUPMAIL = ADDRESS ( Date .applicant — A TEL, J OCCUPANT LOAD NOTICE TO APP LICANT: If, after making this Certificate of c,rY �t 7LZ ��` NO. zb"s�r-3� �" Exemption, you ;Mould become subject to the Workers' AppLl ATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code. you must forth- . with Comply with such provisions or this permit shall be TRAILER USE I 1 GEOLOGY INSPECTION I,^ No Spec. Knowl, deemed revoked. — LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION LZ Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT �] (LIST ITEMS BELOW) ` 9 (commencing with Section 7000) of Division 3of the Busi- NO. OF EXITS ness and Professions Code, and my license is in full force and effect. PARKING SPACES REO'D PROVIDED ��JJ IL��JJ �jG J�r✓ c� License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE TO: I am exempt -roin the !icensing -eauirements as I am a r licensed architect or a re^_istered nrofessional en2inr2er ;aE DF NO. OF INSPECTOR'S ? acting in Iny professional Capacity )Sec ion 70 1. Blas- SIZE NG BLDG. f STORIES SIGN TORE = iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lie. or Res. No. Date /` (J �`//�► HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS V' I hereby affirm that i :tin exempt from the Contractor's ON LOT AND USE ( License Law for the foilowinL reason (Section 7031.5. Busi- ness and Professions Code 1: NO. PARKING 1 (/ —I. OEE V q*-T% I, as owner of the property, will do the work and the SPACES PROVIDED fill(.� structure is not intended or offered rut sale aSection 7044.Business anti Professions Code). CONSTRUCTION LENDING AGENCY F PROPOSED USE OF BUILDING I hereby affirm that there is a construction tendins agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address 25.00 I PERMIT FEE I certify that I have read this application and state that the above information is correct. I agree to comply kith all County ISSUANCE FEE L ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAI- FEE 25.00 upon the above-mentioned property for inspection purposes. I 0 i�gSEE REVERSE FOR EXPLANATORY LANGUAGE t , , �i��%ii �(/nPi� g ►L 3� 'S0natur�?of Dat; { I WORKERS' COMPENSATION DECLARATION 20o063DPW!2/90 MISCELLANEOUS APPLICATION I: I hereby affirm that I have.a certificate of consent to self COUNTY OF LOQ ANGELES BUILDING AND SAFETY DIVISION', f Irinsure, or a certificate of:Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING WnITY NG ADDRESS ,,ll ADDRESS ❑ Certified copy.is hereby.furnished. O ZK /LJ LOCALITY ❑ Certified copy is filed with the county building inspect 'TY Zip p ' department. 7nA L'�" T 7 NEAREST CROSS ST. Date - Applicant - SIZE OF LOT NO.OF SLOGS.NOW ON LOT DISTRICT NO. GROUP TYPE PROCESSED BY CONST. C CERTIFICATE OF EXEMPTION FROM WORKERS' I COMPENSATION INSURANCE TRACT BLOCK LOT NO. MAP HIGHWAY ` NO. (CIRCLE) STATE MAJOR SECOND LOCAL.. (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL by the permit is for one hundred dollars ($100) or less.) USE ZONE SPECIAL CONDITIONS lop er --WNO.. I.certify that in the performance.of the work for which t is iA;AG permit is issued. I shall not employ any person in any man [t.J so as to become subject to the Workers' Compensation Laws. Ess ' OCCUPANCY GROUP u �. DAJ i2'I/c L [ Date Applicant " CIT ��j A zG l0D NOTICE TO APPLICANT: If. after making this Certificate �7 OCCUPANT LOAD of Exemption, you should become subject to the Workers' APPLICATION FOR Compensation provisions of the Labor Code.you must forthwith EXIT HARDWARE: ( comply with such provisions OC this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec. Knowl. revoked. ❑ ' - LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION C Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) a t I 9(commencing with Section 7000)of Division 3 of the Businfrsame o us ness NO.OF EXITS i and Professions Code,and my license is in full force and effe PARKING• REQ'D I I PROVIDED License Number Lie. Class � ` SPACES60 Contractor Date l ? ra LIMITED TIME USE ❑ I am exempt from the licensing requirements as I am a DATE DATE FROM: TO: licensed architect or a registered professional engineer acting in my professional capacity (Section 7051,Business SIZE OF NO.OF INSPECTOR'S and Professions Code). EXISTING BLDG. STORIES GNATURE. Lie. or Reg. No. - Date PRESENT USE OF BUILDING FINAL APPROVAL HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS O j ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and { Professions Code): NO.PARKING SPACES PROVIDED ' ❑ I, as owner of the property, will do the work and th structure is not intended or offered for sale(Section 70 ROPOSED USE OF BUILDING Business and Professions Code). t b/iVim/ f�Alt� D%17 CONSTRUCTION LENDING AGENCY i I hereby affirm that there is a construction lending agency for G the performance of the work for which this permit is issued + I (Sec. 3097, Civ. C.). PROPOSED MAX.OCG Lender's Name APPLICANT(PRINT EL O. Lender's Address !C 3A DRESS { j I certify that I have read this application and state that the above information is correct. I agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction,and hereby authorize representatives.of this County to enter upon ISSUANCE FEE I' tntioned property for inspection purposes. . ., ' TOTAL FEE "-- XM b I SEE REVERSE FOR EXPLANATORY LANGUAGE Si_ ture of Pennittee Date