HomeMy Public PortalAbout10411 LOWER AZUSA RD_Miscellaneous__ i 1VOR;EF,S'CUMPENSATION DECLARATION CE 3-75 i71-84i a MISCELLANEOUS APPLICATION
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thereby affirm That t have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, of a certificate of Workers'Compensation Insurance,or
fes' a certified copy thereof(.See. 3800.Lab.C.). —
='II Poiicv No. Company
FOR APPLICANT TO =•.LL IN ADDRESS
BUILDING
Certified copy is hereby furnished. I BUILDING �!
(ADDRESS /G•y�f�,Cdfl((�R •'/>tJ (' -p LOCALITY
1 —
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. Temple City CROSS ST.
Date Applicant NEAREST DISTRICT Iyy��///}}} GR O P TYPE P ESSED BY
]CROSS ST. y�f zz., j- -e �Sr)� CON
i CERTIFICATE OF EXEMPTION FROM WOR. LEGAL y
LO%'IPENSATION INSURANCE i DESCRIPTION I LOT :NO. IBLOCK nAP HIGHWAY STAT MAJOR SECOND LOCAL
j !NO. OF .BLOGS. NO. (CIRCLE) _
(This section need not be completed It the ,work involved I TRACT NOW ON LOT gUSE ZONEISPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less.) iUSE OF
i SIZE of LOTI
=_X i ST;NG SLDC.
I certify that in the performance of the ',woes for ',which .111s ---- —
permit is issued, I shall not employ any person in n'•'Manner ;v;,ER
so as to become subject to the }Yorkers s
Conipen ,iion Law
:.s. PAIL / J ll?
_CCUPAN� 1( GROUP
11j "D D R E S S ll e l
Date Applicant — -
NOTICE TO APPLICANT: I`, after making this Certincate of X! c �/% �c OCCUPANT LOAD
Exemption. you should become subject cp the "fork,,,' `� Y 6d6 ' 7�
Compensation provisions of the Labor Code, you mas:: ;orifi,- APPL;CA I iGN FOR P;tIT r AnuIAJARE: -
,with compiy with such provisions or this permit snail be ,RAIL R USE GEOLOGY INs?E_T;ON No Spec. Knel:vl. I �
deemed revoked. t _ — 111
Occup:,NCY INSPECT:oN Panic Devices h?
LICENSED CONTRACTORS DECLARATION � ;
I hereby affirm that I am licensed under nrov:sionsof Chapter
;y 'I SAFETY PER:+IIT _:ST ITEMS 3E_!�:':)
I i i
9 (commenc:lL with Semon 1000) of Division 3 Oi il;e BuSi- _ :NO. OF EXITS I
ness and Professions Cede, and my license is n `ull force and
effect. e��D — SP., CESG REO'D � ; ?R OVID ED I II
License Number Lic. Class
LIMITED TIME USE
w Contractor llatz DATE =ATE
FRo is
1 am exempt from the licensing ,eau enxnts as I ani 31
} licensed architect or a registered professional :._aineer j SIZE of C_ Oc NSPECTOR'S
acting in in} professional aCiL�' :Sei ilOn 05:. bila- EXISTING BLDG. STORIE5 SIGN ' RE
inessand?rc_essionsCode). ?F; 1aL APPROVAL
{PRESENT USE OF BUILDING
Lic.or Res. No._ Date
t
HOME OtYNER-BliILDER DECLARATION � NO, OF EXISTING BUILDINGS D0
1
ON LOT AND USE (//1 _
y °�" "— x:�.—
I hereby_ affirm that I am exempt from the Cor.*.: cior's 1 ti) L+ ,ry W -j r._.. I1j? *FP},.
i License Law for the following reason (Section 7031.3, Busi 1 /
ness and Professions Code): No. PARKIRNG
15PA CES POVIDED �� /I,
I, as.owner of the property, will do the work and :he
strucure is not intended or offered -or sale (beciion 1
i 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENPROPOSED USE OF BUILDING
T,
I hereby affirm that there is a construction lending :i=ency ��N '� e, -
1 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
` I certify that I have read this application and state that the PERMIT FEE
25.00
above information is correct. i agree to comply with all County ISSUANCE FEE
ordinances and State laws retating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 25.00
t. l upon the above-mento d property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
(.rl Signature of Permittee Date