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Home My Public Portal About10419 LOWER AZUSA RD_Miscellaneous__ ORKEFtS'COMPENSATION DECLARATION CE 875 (11:84) MISCELLANEOUS APPLICA"T"ION CE 875 I hereby affirm that I have a 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(See. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN ADBUDREILDING JQ j 3 SS! L'_�//_✓n_/✓�.v/ Certified copy is hereby furnished. uILDING / LOCALITY 6 ADDRESS Certified copy is filed with the county building inspection 11 LOCALITY NEAREST department. CROSS ST. Date Applicant EAREST DISTRICT NO. G U TYPE P SED BY CROSS ST. C Zi CONST. / CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGRw AY STATE MAJOR SECOND LOCAL NO./1/1/-173 (CIRCLE) NO. OF BLD GS. (This section need not be completed,if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS USE OF by the permit is for one hundred dollars ($100) or less.) SIZE OF LOT EXISTING BLDG. � I certify that in the performance of the work for which this CD permit is issued, I shall not employ any person in any manner owr1ER y so as to become subject to the Workers' Compensation Laws. MAIL q� ��y-� OCCUPANCY GROUP � '� o Date Applicant ADDRESS �� a l (N/�-� - w NOTICE TO APPLICANT: If, after making this Certificate ofv CITY OCCUPANT LOAD D Exemption, you should become subject to the Workers' N z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION EI deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION DU Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING SPACES REQ'D D PROVIDED O License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a M. TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING ✓�v Lie.or Reg.No. Date / HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ❑ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). z 6 0 7.3 A 14 CONSTRUCTION LENDING AGENCY RoeosEo USE of BUILDING19 00 # aa • • 88 I hereby affirm that there is a construction lending agency .�J4-' • a a o o • e In for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). 1 2 0 8 3 8 6 Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon t above-mentioned property for inspection purposes. /�_�� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee l/ Date CORKERS'COMPENSATION DECLARATION 76M444 M I S C E L LA N E O U S ;A P P L I C A T ION . {� CE 875 (2-80) (� I hereby affirm that I have a 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. Company FOR APPLICANT TO FILL IN BUILDING. /9 ADDRESS ((�J ❑ Certified copy is hereby furnished. UILDING .0 / �L� . ADDRESS Ylv LOCALITY F-1 Certified copy is filed with the county building inspection h NEAREST I department. ocALIrY 9 IfA, CROSS ST. Date Applicant EARESTDISTRICT NO. GR 2,P2P TYPE PROCE�ED Y CROSS ST. , /�/'9 CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J o DESCRIPTION LO NO. BLOCK } COMPENSATION INSURANCE "I�"wAv NO. No. (CIRCLE) STATE MAJOR SECON LOCAL d NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT 2,- USE ZONE SPECIAL CONDITIONS OU by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG.006. 'I certify that in the performance of the work for which this .5 X90 O permit is issued, I shall not employ any person in any manner OWNER G f- so as to become subject to the Workers' Compensation Laws. �[��/�// J�1�� OCCUPANCY GROUP V AI '� a ARESS LU Date Applicant rn TEV Z .NOTICE TO APPLICANT: If,after making this Certificate of CITY PArvo. .l�� /$ OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- AP LIGATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec. Knowl. deemed revoked. Panic D@VIC@S ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) rvo. of EXI ❑ 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and PARKING. effect. SPACES REO'D PROVIDED License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ❑ I am exempt from the licensing'requirements as I am a licensed architect or a registered professional engineer SIZE OF. �O a NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE mess and Professions'Code).' FINAL APPROVAL RESENT USE OF BUILDING Lic.or Reg:No. Date '^\ HOME OWNER-BUILDER DECLARATION No. of EXISTING BUILDINGS / j D ON LOT AND USE � � 11./_ -(/�// . I hereby affirm that, I am exempt from the Contractor's 9 1 9 9.2'A - License Law for the following reason (Section .7031.5, Busi e o e o Y Y ness and Professions Code): NO. PARKING SPACES PROVIDED Q,{ m r z (J ❑ I, as owner of the property, will,do the work and the - G structure is not intended or offered for sale (Section 07 85 7044, Business and Professions Code). ROPOSED USE OF BUILDING ,- CONSTRUCTION LENDING AGENCY I hereby affirm. that there is a construction lending agency C All 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 PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL. FEE and hereby'authorize representatives of this County to enter u o he above-Snentioned property f inspe Ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ti WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec. 3800,Lab.C.), r Policy No. ` Company FOR APPLICANT TO FILL IN BUILDING �,`/G ADDRESS `T Certified copy is hereby furnished. wooaess d ey LOCALITY 6 0 Certified copy is filed with the county building inspection LOCALITY , NEAREST department. CROSS ST. Date Applicant NEAREST I ! DISTRICT NO. GRAAUP TYPE CESSED BY CROSS ST. 'D� �� CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (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 ($100) or less.) US OF of //// SIZE OF LOT EXISTING BLDG. /- tea` I certify that in the performance of the work for which this V o permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP i�/,.ro ADDRESS — Date Applicant LU TEL. NOTICE TO APPLICANT: If, after making this Certificate of clrY No. OCCUPANT LOAD � Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLI ATION FOR i0 ��07/� EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code, and my license is in full force and effect. —t-- PARKING10 SPACES REQ'D PROVIDED License Number Lie. Class 5erkllC LIMITED TIME USE Contractor Date DATE DATE - ,3 I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF aN OR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING ✓- Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS lot "'- ON LOT AND USE �� pp ( I hereby affirm that I am exempt from the Contractor's , License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING V_ I hereby affirm that there is a construction lending 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 ' I certify that I have read this application and state that the PERMIT FEE above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, '" and hereby authorize representatives of this County to enter TOTAL FEE "Upon the above-t entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE sign�fu�e o ermitte / Date