HomeMy Public PortalAbout9350 LOWER AZUSA RD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I laffirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insureure,, o`r a certificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.Q. �/1�
Policy No. Company FOR APPLICANT TO FILL IN ABUILDING
DDRESS 31 0
Certified copy is hereby furnished. L MILDING LOCALITY `
ADDRESS
Certified copy is filed with the county building inspection f1 NEAREST
department. OCALIry CROSS ST. Ct 0
Date Applicant10 EAREST DIS`,,IC NO. GR UP TYPE 1PROQQQ 'ED BY
CROSS ST. Q5/ CONST./
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NMA OP I� HIGHWAY(CIRCLE) STATE MAJOR SECON 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.) 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 OWNEXISIC y
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
AIL o
ADD ESS EKE]
UDate Applicant
I„
TEL. OCCUPANT LOAD
NOTICE TO APPLICANT: If,after making this Certificate of CIr1 NO. y
Exemption, you should become subject to the Workers'
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 ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
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 and
effect. PARKING REQ'D O PROVIDED O
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
EJI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES A 6 I RE
iness and Professions Code). FINAL APPROVAL v
Lic.or Reg.No. Date RELOT AND USE USE OF BUILDING T-ow-ing Business
fJ
0 0 0 0 0 0 o z
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS o212-87
ON
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 RorosED USE OF BUILDING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is Vpblcle
issued(Sec.3097,Civ.Q.
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
up , th above-ment' ed property for inspec on purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perm tee, �/Q D to