HomeMy Public PortalAbout10667-10669-10671 LOWER AZUSA RD_Miscellaneous__ WORKLRS' (O1`v1l'l-NSAllON DE( LARN110N
MISCELLANEOUS APPLICATION .
I hereby afTirm that I fu\c it ccrlit'icdie Of COWcm to scI1 C0111N] Y 01- 1 OS A NG F I.,1-5 131111-DING AND SAFETY DIVISION
insure,or it ceitif"icatc of Workers' (ompciisiiiion hmii,imc, ,I II
it certil'ied cop) thereof (Sec. 3800. klh. ( I .
j Policy No. Company' FOIL APPLICAN I TO FILL IN BUILDING
BUILDING ADDRESS ADDRESS
El (ertil'ied cop) is hcrehy ItimiNlied. —cell ;,.CALITY
ElCertified cops is filed with the,-,omm huildim., iii,,I)cclion CIT) ZIP
NEAREST
;ROSS I,- ;ROSS ST.
Date Applicant STRICT NO, GROUP TYPE PROCESSED BY
CONST.
E-1011:1( AIT OF EXEM1111ON 1AZON1 WORKHV�
LOT NO.
1— (CIRCLE) STATE MAJOR SECOND LOCAL
COMPLNSAHON INSURAW L TPACT BLOCKaAF HIGHWAY
(This.stec(ion iieed iaot be compIcled it' the woikhed m
ioMAP BOOK PAGE PARCEL
)) ()I less.) USE ZONE SPECIAL CONDITIONS
by the pelmil is For one 111111thed dollals (.,�. 10(
EL 0
OW
I celtity thill ill ell' Vdla
jumil is isslicd. I shall not 1plo� miN fl"i�ojl I I it i It\ III urn,I A k')I Z E S
so its to hecomc subject to file W'mkci,' ( ompt, 111 n1 11 l\1S.1 OCCUPANCY GROUP
Date Applicant CITY
NOFl(T 'lO APITICAN 1: 11. asci making this ( cmllrMc
OCCI JPAN T LOAD
of Exclul)(ioll, \oil shotilif become "Ibiccl lo file Wolkcl�' APPLICAI ION I ()I
'('OIIIpeTISaIIOII [)to\iSiOIIS Of IIIC LilhOl.CodC,sou 11111SI I'll 111\k 1111 — LXlf I fA(?DVVAIIE::
Comply �Nith such p1misions or fill, pellitit shall hC deemed TRAILER USE[ 1 GEOLOGY INSPEC I ON No Spec.Knowl.
revoked.
❑
HCENSH) CONIRACI ORS DI (T A RAI l()N ------- OCCUPANCY INSPECTIONX Panic Devices
I hereby aft iIII1 that I aill licensed llildcl provisions of ( hill)[el. SAFETY PERMII iLiSF ITEMS BELOW,
9(commencing with Section 7000)of Division I of'file Business NO.OF EXITS F
and PrOl'essions(-ode. and fit\ license is in I'Lill I-oice and effect.
UAII 11711,, 1,-5 PARKING:
License Numhei Lic. Cklsti _SPACES REQ'D = PROVIDED
Cmnllacll,l 1);lIc ---001 iy dc LIMITED TIME USE
DATE DATE
D I am exempt front the licensing requirements as I am it FROM: TO:
licensed architect or it registered piol-essional cneinecr
INSPECTOR'S
SIGNATURE
acting i I Ill) piolessional capiicii\ (.Scclion 7(M. liwiillcss SIZE
and Plot EXIS I INC;HLDG.
Icssiolls (Mlle
12—
LIC. or Reg. No. Date PRESENT USE OF BUILDING FINAL APPROVAL
I R)M I OW N 1:R-lit III I M,R IA LA VA I 1()N I'JI),Of I:XISIINGBUII-LlINGS
ON LOT AND USE
I hereby alhim that I and c\cilip( hoill Ilic Contractor's Licclisc
Law for the. following reason (Section 70.11 >. Business and
Professions (ode): NO�PARKING
5PAC
ES PROVIDED
❑ 1. its owincl of' the ploper:t\. will If,, the N\,,ik mmd Ilw ---
sirticime is not intended Of ollcicd I"i salc (Sccl,ioll 711.1 I. PROPUS I ED USE 01 BUILDING ✓ 'lot
Business -01'eSSiOlIS Cmic)
ard PI
CONSTRUCTION LENDING AGI N( )i
I hereby iliTirill Ill;111 tllCie is it C011SIHIC111011 ICIILIIIU� I'
Ille f)erl'ormimIi
cc o' ic voTk lot \\hich ihir pcimit is issued. ---------
(Sec. .1097, (IV. PROPOSED MAX.OCC.
NT iP 141
Lender's Name APPOLI11,'�I !etTr NeL (:I
Lender.7s Address S., rq
ADD S
I certil'y that I havc-read this application and state that 111c
above inf'orniat ion is correct. I agree to comply kith all County y PERMIT FEE
ordinances and State laws relating to building construction.and —
hereby authorize representati%cs Of this Comm to enter upon 15SLJANCE FEE
the above-mentioned property 1 inspection pmp(,scs.
AA
-/- /-,�4-RL.VERSl: FOR EXPLANATORY LANGUAGE
/SigilitUlIC 01* Pernimee Dute
WORKERS'COMPENSATION DECLARATION E87a5 (11-84)
CMISCELLANEOUS APPLICATION
• CE 8
re COUNTY affirm that I have a certificate of consent to self
' COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 3
sure, 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
ADDRESS
� Certified copy ishereby furnished. BU ILDIria LOCALITY
XX ADDRESS l
ID Certified copy is filed with the county building inspection LOCALITY /) p NEAREST
department. X -(' �-_' G��� CROSS ST.
XX
Date Applicant NEAREST. DIST R'A�. ;Fp
CONS!Z:ITYPE CESSED BY
.CROSS ST1.,�
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.) t USE OF
I certify that in the performance of the work for which this �( ��j>+� -"\ \: -O2 >-
SIZE OF LOT EXISTING BLDG.
CD
permit is issued, I shall not employ any person in any mannekX owNER Of bui1din g :6pEc!Mu- NE• f +r r
so as to become subject to the Workers' Compensation Laws. MAIL ) , OCCUPANCY GROUP E :]
f c)
ADDRESS.) � �. `L� � C�'/��iY e.7 � C?
Date Applicant .cel LLI
NOTICE TO APPLICANT: If, after makingthis Certificate of CITY No. s ®� 7 OCCUPANT LOAD ��
L.�. X73, _)7
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions OI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 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 3 of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force anix
effect. NSffie Of business PARKING` REp'D PROVIDED
SPACES
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
NO. OF INSPECTOR'SIGNA
acting in my professional capacity (Section 7051, BBS EXISTING BLDG. 4�G/� '�— STORIES l SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING i aAdLfl �j�L Fit:AL.APPROVAL A7 -'
Lic.or Reg.No._ Date �-`� `
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USEn_Y: .. ...._......_..
Vry �...... ._-....
hereby affirm that I. ani exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- I". L. "� - .• l�l"'c��i ' .
ness and Professions Code): NO. PARKING
.SPACES PROVIDED
I, as owner.of the property, will do the work and the r
structure is not intended or offered for sale-(Section `''
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY 'PROPOSED USE OP BUILDING
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.). 7+!►D�i1:�1 ,®i `t
LendeI'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 d State laws relating to building construction,
and here y uthorize presentatives of this County to enter TOTAL FEE 25 - 00
upon tl ab ve m ti ed prop for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
1 l XX
y. Signature of"Permitice Date
r