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Home My Public Portal About9578 LOWER AZUSA RD_Miscellaneous__ WORKERS COMPENSATION DECLARATION 00063L>PW 12/80 2MISCELLANEOUS APPLICATION I 20 06 C e I I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Il 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 _ J BUILDING A_WRESS f1 AD SS A- J� ® Certified copy is hereby furnished .7Mr Z/4 9-Y LOCALITY I Certified copy is filed with the county budding Inspection cmr ZIP i department *y Ips pz� G ��78 V NEAREST .iA I�"'•/ CROSS ST g' C. Date Applicant SIZE OF LOT NO OF BLDGS NOW ON LOTDISTRICT JZUP I TYPE PFRbCESSED BY u CERTIFICATE OF EXEMPTION FROM WORKERS TRACT BLOCK LOT NO CONST J COMPENSATION INSURANCE MAP HIGHWAY i No ICIRCL11, STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE "ITIONS I by the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this OWNER ILIL i I permit Is issued I shall not employ any person In any manner �1S!'N1J SIV gas Soft I t so as to become subject to the Workers Compensation Laws ADDRESS OCCUPANCY GROUP Date Applicant CITY zip ' NOTICE TO APPLICANT If after making this Certificate ac OCCUPANT LOAD of Exemption you should become subject to the Workers APPLICATION FOR Compensation provisions of the Labor Code you must forthwith EXIT HARDWARE comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑ revoked E]LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter PERMIT❑ (LIST ITEMS BELOW) 9(commencing with Section 7000)Of Division 3 of the Business NO OF EXITS and Professions Code and my license is in full force and effect FETY PARKING REQ D D PROVIDED D I License Number Lic Class sPAces Contractor Date LIMITED TIME USE DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer acting in my professional capacity (Section 7051 Business SIZE OF NO OF INSSPECTOR S RE and Professions Code) EXISTING BLDG sTORIE$ Lic.or Reg. No Date PRESENT USE OF BUILDING FINAL APPROVAL i HOME OWNER BUILDER DECLARATION NO OFEXISTING BUILDINGS L ON LOT AND USE I I hereby affirm that I am exempt from the Contractor s License "vJr V Law for the following reason (Section 70315 Business and U, i Professions Code) NO PARKING V I 1 as owner of the property will do the wort and the SPACES PROVIDED structure is not Intended or offered for sale(Section 7014 PROPOSED USE OF BUILDING Business and Professions Code) ' CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for AWFVW I the performance of the work for which this permit is Issued (Sec. 3097 Civ C) PROPOSED MAX OCC. Lender s Name APPLICANT(FRWr) NaeO G7 Lenders Address ADDRESS I certify that I have read this application and state that the above information is correct i agree to comply with all County PERMIT FEE ordinances and State laws relating to building construction and hereby authorize representatives of this County to enter upon ISSUANCE FEE the above mentioned property for inspection purposes 1 TOTAL FEE 191, I Ilk, _ _ _ �� v SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS COMPENSATION DECLARATION CE Bis(2 80) MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure or a certificate of Workers rs Compensation Insurance e or a certified copy thereof(Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN BAUILDIj6 DD RE88NG ❑ Certified copy is hereby furnished BUILDIN �1 1 nIW�- `1C A, LOCALITY ❑ ADORES ` W v�� Certified copy is filed with the county building Inspection NEAREST department LOCALITY 1 �1 A CROSS ST Date Applicant NEAREST l J(� V ` `l DISTRIC O GR TYPE PR C SSED BY CROSS 8T I Q�f v : i CONS CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL 1V 1 7 — COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY No (CIRCLE) STATE MAJOR SEC D LOCAL d (This section need not be Com leted if the work involved TRACT NO OF BL NOW ON LOT T USE ZONE SPECIAL CONDITIONS O V 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 owivER O permit u Issued I shall not employ any person in any manner ^ V so as to become subject to the Workers Compensation Laws MAIL �M /t A 4 ` OCCUPANCY GROUP W ADDRESS 5 (TN'r tfxA J��'L' a Date Applicant � to NOTICE TO APPLICANT If after making this Certificate of clTr t7V1�{Ar No 4p /I Ig L) 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 USE 0GEOLOGY INSPECTION deemed revoked 0 NO Spec Kt10Wl El ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO OF EXITS ❑ 9 (commencing with Section 7000)of Division 3 of the Busi ness and Professions Code and my license is In full force and effect 1 5PACESG REO D O PROVIDED License Number LIc Class i 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 S acting In my professional Capacity (Section 7051 Bus EXISTING BLDG STORIES SIGNATURE mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL LIc or Reg No Date HOME OWNER BUILDER DECLARATION ON LO O EXISTING BUILDINGS OT AND USE I hereby affirm that I am exempt from the Contractors ;1161 2A License Law for the following reason (Section 7031 5 Busl ness and Professions Code) NO PARKING # 8 SPACES PROVIDED ❑ 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) a a PROPOSED USE OF BUILDING i^ CONSTRUCTION LENDING AGENCY 0 2 2 8 1 8 5 1 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 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 REE and hereby authors a Wpresentatives of this County to enter uponh ab a ed property for inspection purposes _SEE REVERSE FOR EXPLANATORY LANGUAGE r Ss nature of Perm ttee Date WORKERS COMPENSATION DECLARATION CE 875 4(2 80) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent self 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) Policy No Company FOR APPLICANT TO FILL IN BUIADDLDIRE'SS'❑ Certified copy Is hereby furnishedBu1LDING ,!,^RR LOCALITY ❑ ADDRESS TF WP— Certified copy Is filed with the county building inspectionNEAREST A department i. LOCALITY rj • ,�. CROSS BT Date Applicant NEAR HST DISTRICT NO GROUP TYPE PROC ED B CR0889T O CONST/ CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL L COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK NOP �lHIGHWAY I } �J (CIRCLE) STATE MAJOR SECOND LOCAL a NO OP BI VV^` (This section 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 y SIZE OF LOT EXISTING BLDG �/^ tr I certify that in the performance of the work for which this 0 permit is issued I shall not employ any person in any manner �' OWNER I- so as to become subject to the Workers Compensation Laws AIL OCCUPANCY GROUP �� W ADDRESS LL Date Applicant Z NOTICE TO APPLICANT If after making this Certificate of t CITY NOL - 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 USE❑ GEOLOGY INSPECTION 11NO Spec Knowl Eldeemed revoked ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic DeVIC@S I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT i-d (LIST ITEMS BELOW) NO OF EXITS ❑ 9 (commencing with Section 7000) of Division 3 of the Busi ness and Professions Code and my license is in full force and PARKING II�I effect REQ D PROVIDED SPACES Lr ense 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 Of 8 registered professional engineer SIZE BUS OF O OF INSPECTOR s X acting in my professional capacity (Section 7051 EISTING BLDG STORIES SIGNATURE mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Llc or Reg No Date VQ C cklock HOME OWNER BUILDER DECLARATION No O EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Busi ness and Professions Code) NO PARKING SPACES PROVIDED ❑ I as owner of the property will do the work and the ;91 6 6 2 A structure is not intended or offered for sale (Section 7044 Business and Professions Cod ei) D # •{• • • 8 8 PROPOSED USE OF BUILDING i { r CONSTRUCTION LENDING AGENCY • •1• •I• • • I hereby affirm that there is a construction lending agency ' 023-81 2 ^8 1 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 O I certify that I have read this application and state that the above information Is correct I agree to comply with all County IssuAlvcE FEE ordinances and S90e Paws relTOTAL FEE ating to building construction and he ze r�po this County to enter Q� uge h en Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE ' 10 Signature of Permi tee Date WORKERS COMPENSATION DECLARATION CE 875(2 80) MISCELLANEOUS APPLICATION 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) 4 p Policy No Company FOR APPLICANT TO FILL IN BUILDING ✓ �t>r ADDRESS v ❑ Certified copy is hereby furnishedILDING P / 7�5 LOCALITY DDRESS Q /—(/ ❑ Certified copy is filed with the county building inspection NEAREST department fic CALITY CROSS ST Date Applicant AREST ,p , DISTR T NO GROUP TYPE I PR ESSED BY O88 ST `M I '�"1 1D y CONST /'�/ CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL CJ COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY } NO (CIRCL¢) STATE MAJOR SECOND LOCAL (This Section need not be completed if the work involved NNOW O OF ON BL TRACT LOTT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE OF SIZE OF LOT EXISTING BLDG Q I certify that in the performance of the work for which this , permit is issued I shall not employ any person in any mannerNER so as to become subject to the Workers Compensation Laws OCCUPANCY GROUP a fMAIL DRESSPO&1 6614 � y Date Applicant PJ TEL z NOTICE TO APPLICANT If after making this Certificate of ...r_Y $0alloOCCUPANT 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 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 Q (LIST ITEMS BELOW) No OF EXITS ❑ 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 REO D PROVIDED SPACES License Number Lic Class LIMITED TIME USE Contractor Date D A T H DAT s ❑ I 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 SIGNATURE mess and Professions Code) RESENT USE OF BUILDING U r\ 0 h FINAL APPROVAL Lic or Reg No Date NO RX TING U�r,1 TING BUILDINGS DODO— 1/14/r- HOME OWNER BUILDER DECLARATION ON LOO T AND USE JJ�� ' I hereby affirm that I am exempt from the Contractors q� 1131 1 FM e,iio License Law for the following reason (Section 7031 5 Busi ness and Professions Code) SP PARKING (►.1�1 SPACES PROVIDED Y ❑ 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) ss..--�� IT ROPOSED USE OF BUILDINu , i�_KC, CONSTRUCTION LENDING AGENCY / V I I hereby affirm that there is a construction lending agency II L -. -V 2=4t for the performance of the work for which this permit is issued(Sec 3097 Cry 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 he y authorize representatives of this County to enter upon bove men o d p�petty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of a mittee Date