HomeMy Public PortalAbout9415 LOWER AZUSA RD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE B75(11-B4) MISCELLANEOUS APPLICATION
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.Q.
Policy No. Company FOR APPLICANT TO FILL INBUILDING I otp-
ADDRESS
Certified copy is hereby furnished. BUILDING J 1 �•.1 LOCALITY
ADDRESS J 1.1I ,cc.►
ElCertified pis filed with the county building inspection LOCALITY ^ NEAREST
CROSS ST.
Date Applicant NEAREST T DISTRICT O. iGR P TYPE PROCESSED BY
CROSS ST. ` 3_ C T.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR J ND LOCAL
NO. (elReLe)
NO. OF BLDGS.
(This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
I certify that in the performance of the work for hick this SIZE OF LOT EXISTING BLDG. aC�
permit is issued,I shall not employ any person ' manner OWNER N� �I- �'!�� SD
so as to bec7AAPPLICA'
subject to the W rke M' Co pe satin aws MAIL 153 OCCUPANCY GROUP II ,/C` i'`�/ II o
O. A h t ADDRESS • L�LJ�LJ h-
Dat �j r
PA n � TEL' + I�,7 �•�� 1 OCCUPANT LOAD W
NOTICE T : If, r aking this Certifi a of CITY 0 1!r No. Com- y
Exemption, you - Ll become subject to the W rkers'
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
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 0
I hereby affirm that I am licensed under provisions of Chapter' FETY 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 I SSR P.?�:PMI f �� V
effect. PARKING
` p SPACES
� REq D D PROVIDED
License Number Lic. Class I V ' ?acL b l L-� &.T is. UNITif
i �� � LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a, FROM' TOI
licensed architect or a registered professional engineer SIZE of NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S1. NATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.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 9 5 0.7 A
License Law for the following reason (Section 7031.5, Busi
ness and Professions Code): NO. PARKING # o 0 0 0 3 0
SPACES PROVIDED
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ) o o 80,50
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING o D 8 0 5 0 9 .
I hereby affirm that there is a construction lending agency 0 5 0 2-8 8
for the performance of the work for which this permit is
issued(Sec.309
Lender's Name
PROPOSED MAX. OCC.
Lender's Address�l.- �f>�
PERMIT FEE 706V 1
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 QI
ordinances and State laws relating to building construction, l�---7'
and hereby authorize representatives of this County to enter TOTAL FEE l v
u ove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date