HomeMy Public PortalAbout9324 LOWER AZUSA RD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875(2-80) OS C E L LA NE®U S APPLICATION
I he.e d affirm that I have certificate of consent to self COUNTY OF ]LOS ANGELES BUILDING AND SAFETY DIVISION
insure, dr a certificate of Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLIC NT TO FIL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. BUILDING2 A LOCALITY
ADDRESS d
❑ Certified copy is filed with the county building inspection NEAREST .41
department. LOCALITY CROSS ST.
llate Applicant NEAREST DISTRICT NO. I GROUP ITYPE PR CESSED BY
CROSS ST. �DLle _7 CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
STATE MAJOR SECOND LOCAL
NO. (CIRCLE) tl
NO. OF BLDGS.
(This SOCtIOn need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.) ,
USE OF
SIZE LO XISTING BLDG.
I certify that in the performance of the work for which this Q
permit is issued, I shall not employ any person in any manner D ER i—
so as to become subject to the Workers' Compensation Laws. MAIL � QCCUPANCY GROUP �C�J��J W
ADDRESS - oT /L• "—
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CIT �o� �$ ✓ OCCUPANT LOAD
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 or this permit shall be TRAILER USEGEOLOGY INSPECTION
❑ ❑ No Spec. Knowl.
deemed revoked.
OCCUPANCY INSPECTION❑ Panic Devices
LICENSED CONTRACTORS DECLARATION ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT V (LIST ITEMS BELOW) NO. OF EXITS El9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and .fir
effect. V i SPACESG' REq'D PROVIDED
License Number Lic.Class �e'E " ,SIvice i Re6S
LIMITED TIME USE
Contractor Date DATE DATE
PROM: TO:
F11 am exempt from the licensing requirements as I am •r.
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING �a �
Lic.or Reg.No. Date 2 +3
'1 �2—
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS w
ON LOT AND USE n/
I hereby affirm that I am exempt from the Contractor's �1{j'y l '; ;"!"+_
License Law for the following reason (Section 7031.5, Bus)-
ness and Professions Code): NO. PARKING Jaaq�I'InIIL" ^_
SPACES PROVIDED 1" - y r".'7 �s'.••
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PROPOSED USE OF BUILDINGC
Al
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performanceof 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
dinances a State laws r in to building construction, TOTAL FEE
an hereby horire repr ent es of this County to enter
up a bo -mlentione roperty for inspection 1 urpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date