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Home My Public Portal About9580 LOWER AZUSA RD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M4 % CE 875(2 80) MISCELLANEOUS APPLICATION 1 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) Policy No Company FOR APPLICANT TO FILL IN BUILD NG Q ADDRESS ❑ Certified copy is hereby furnished BUILDINGp �� p w �,�/ LOCALITY O ADDRESS a ❑ Certified copy Is filed with the county building Inspection NEAREST department LOCALITY /JiJ7 at CROSS ST T Date Applicant NEAREST /'i(r L / DISTRICT NO GROUP' TYPE PROC SSED CROSS ST G! ��+ D 6 CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION Lor NO BLOCK NOP a (C RCLEY } ^ STATE MAJOR SECOND LOCAL t1 (This section need not be completed If the Work mVOIVed NO OF LOGS ;Scz- E ONF CIAL CONDITIONS V P TRACT NOW ON LOT by the permit Is for one hundred dollars ($100) or less) usE of � SIZE OF LOT Z f�&(� SQ 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 OWNER 1,CVK"Atfje p J4f0 H so as to become subject to the Workers' Compensation LawsMAIL �/Il f tt OCCUPANCY GROUP _ W ADDRESS_ � Date Applicant Z NOTICE TO APPLICANT If after making this Certificate of cirY �jCi6,� irvoL ��(oo7t'p 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 E] GEOLOGY INSPECTION C1 No Spec Knowl ❑ deemed revoked ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION� Panic Devices I hereby affirm that I am IlLensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) NO OF EXITS a 9 (commencing with Section 7000) of Division 3 of the Busl ness and Professions Code, and my license is in full force and PARKING effect SPAG ES REO D D PROVIDED D License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE ❑ FROM TO I am exempt from the licensing requirements as 1 am .L licensed architect or a registered professional engineer SIZE OF �O No OF INSPECTOR S acting in my professional capacity (Section 7051 Bus- EXISTING BLDG 10.41Q 3v� STORIES / SIGNATURE iness and Professions Code) y� FINAL APPROVAL PRESENT USE OF BUILDING F. Lic or Reg No Date HOME OWNER BUILDER DECLARATION No O EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5 Busi Al 9 S 7 A ness and Professions Code) NO PARKING SPACES PROVIDED ❑ 1, as owner of the property will do the work and the # e * a a 88 structure Is not intended or offered for sale (Section 7044, Business and Professions Code) E PROPOSED USE OF BUILDING � C`L,.�/1� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a LonstruLtion 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 1 have read this application and state that tht, above information Is correct 1 agree to comply with all County ISSUANCE FEE (/ ordinances and State laws relating to building construction, TOTAL FEE and hereby authorlre representatives of this Countv to enter �140 upon the dbov mentio d property fopection purposes SEE REVERSE I OR EXPLANATORY LANGUAGE b�JI/ Signature of Permittee Date . WORKERS'COMPENSATIONDECLARATION CE 875(280) MISCELLANEOUS APPLICATION I hereby affirm that I ha%e 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) Policy No Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished LogUILDING Q / _�� US LOCALITY ADDRESS Lo ❑ Certified copy Is filed with the county building Inspection LO ALITY G Zr /��. NEAREST department � � G �i L1V• CROSS sr Date Applicant EAREsT T'�J/1 T /�� DISTRICT 1�O G UP TYPE PROLES D BY CROSS ST ` '�S77Ii/ Li V 5 AJC/ ��J CONST CERTIrICATE Or EXEMPTION FROM WORKERS LEGAL �(�Vi L COMPENSATION INSURANCE DESCRIPTION I LOT No BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SEGO LOCAL d NO OF BLDGS O (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 OF i 512E OF LOT EXISTING BLDG O 1 certify that in the performance of the work for which this H permit is Issued, I shall not employ any person in any manner 1,115wriallW2�= G V so as to become subject to the Workers' Compensation Laws AIL / OCCUPANCY GROUP //�� W go ADDRESS C,O•Vm Z�JS� ��' IIVI�� a Date Applicantto Z NOTICE.TO APPLICANT If, after making this Certificate of P rITr ;f r— C,77 OCCUPANT LOAD Exemption, you should become subject to the Workers gppLICA ION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth with comply with such provisions or this permit shall be TRAILER USE 0 GEOLOGY INSPECTION NO Spec KnOWI ❑ deemed revoked Panic Devices ❑ LICENSLD CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO OF EXITS E-19 (commencing with Section 7000)of Division 3 of the Busl ness and Professions Code and my license is In full force and PARKING effect SPACES REO D E=:= I PROVIDED License Number LIc Class LIMITED TIME USE Contractor Date DATE DATE F1FROM TO I am exempt from the luensing requirements as 1 am a licensed architect or a registered professional engineer SIZE OF No OF iNs ECTOR s acting In my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES �I GNATURE iness and Professions Code) 1. SENT USE OF BUILDING v ,V V /4C�`� FINAL APPROVAL Lic or Reg No Date . . . . 88 HOME OWNER BUILDER DECLARATION No O EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's O O 9`$6 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 structure Is not intended or offered for sale (Section 7044, Business and Professions Code) so ROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY �`G� I hereby affirm that there Is a construLtion lending agency -71-�l7 virJt()J rJ" for the performance of the work for which this permit is 7v�I issued(Sec 3097 Civ C) Lender's Name PROPOSED MAX OCC Lender s Address PERMIT FEE I certify that I have read this application an state that the above information Is correct 1 agree to comp) f with all County ISSUANCE FEE ordinances and State s plating to bull ng construction, TOTAL FEE ereby a ori7 represe tat ives f th Cou ty to enter upo a ov m I erty r I spe on K-7-0-er s REVERSE I-OR EXPLANATORY LANGUAGE ure erml Date WORKERS COMPENSAIION DECLARATION t0006jiPW1, 90 MISCELLANEOUS APPLICATION 1 I hereby affirm that I hail a LCItifiLatL 01 LonsLnt to ,LII COUN'I N' OF LOS ANGFL ES BUILDING AND SAFETY DIVISION II I Insure or a Lertll Icate of Worktrs (olllpLlls 111011 Instal HILL Or a a certified Lop) thereof (Sec 1800 Lab C) POIIL) No (ompally FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS nn ADDRESS ® Certified copy is htrLb) furnished Y Ciy5ro r r�,UI LOCALITY Certified copy is I IILd with the count) bUlldln.In IILLI1011 CITY ZIP NEAREST department —A4'n 1110— CROSS ST Date AppllLalllt SIZIE OF LOI NO OF BLDGS NOW ON LOT "ISTRICT NO GROUP TYPE I PROCESSED BY cl CONST I (ERTII I(AI I Of EXLMP1ION I ROM WORI%I Rti TRACT BLOCK LOT NO �- J (OMPLNSAI ION INSURAN(E MAP MICMWAY L • NO ,LIRCLEI STATE MAJOR SECOND LOCAL (This sttlion rated not Ile complLlcd If lila Nllrlt an%ol%t(I ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIALIRCLE1 IONS 1 h) Iht permit n for out hundred dollais Is 1001 ill It%%) �� I 1 LLrtlfy that rat tilt pi rlollllanit ui 111L tout Ian vthlLII 11111 OWNER I TEL NO ! 1 I pLrmlt Is IssuLd 1 shall not LmplO) an) pLition ill 111) 1111111111 — C 1,- I SO aS to become subject to tht. Wolhers (ompulsaLion 1 les ADDREST / OCCUPANCY GROUP—A 3 ® a Date AppIILant CITY ' ZIP "- NOTICE TO APPLICANT II JIILI making this. (ll all it.tie soo04 OCCUPANT LOAD of Exemption You should become subject to the WOrl,lrs / APPLICATION FOR EXIT HARDWARE ' Compensation provnlons of the Labor Code )ou nnnt lorthwlth rI--77 comply with suLh pro%ISIons or tills pLrnnt sit if] bt dttlll'(f TRAILER USE❑ GEOLOGY INSPECTION 1.1 _ I I revolted Q�1I No Spec Knowl ❑❑ LICENSED CONTRAC FORS DE( I AR 1FION OCCUPANCY INSPECTION101 Panic Devices i I hereby affirm that I am hcensed undLr plot i%ions of (It ipttr SAFETY PERMIT O LLIST ITEMS BELOW I 1 I 9(commencing with SLLtion 7000)of Dia Ision 1Of till Business NO OF EXITS R a I �/ and Professions(odt. laid any licoise Is Infull Io1LL and I nLLI eL� �7�tlLIN�SS _ PLRKING LICCl) IIst Number (IL (1 Iss L11j _ SPACES REQ D PROVIDED 1 I ( Illl ica tal Dlll --nom ��- -- -– —- LIMITED TIME USE DATE DATE ❑ I am exempt from the licensing rt 41I11L1114.11ts as I ,Ina a FROM TO IlLemed architect or a regi%tLrLd PIOILtisuaidl LngolLLr ' acting Ill Ill) pl(11t.ssltlllall LAPdLll) (ILL tion 7011 IIt1%II1Lss SI EOF I INSPECTOR S w) ' and PlolL%%ions(odL) IEXIS rINI.BL DG STORIES _ _ SIGNATURE LIC or Rtg No I)IIL �a PRESENT USE OF BUILDING FINAL APPROVAL �0� I � - IIOME OWNI-R-BUIL Dl It DI( I Alt AlI N NO OF L XISTING BUILDINGS I ON LOT AND USE I I htrLb) affirm Ili 11 I a it Lmmipi Ilona flit.(onll 1Ltln s I ItLn.L -- Law for thL following leason (SLLlloll 7011 '1 1111%II1Lss and l Professions Code) No PARKING SPACES PROVIDED as oitntr of till pmpLlli tt111 du IIIL %%Oi1, 11ld lilt ------ salutltlrL Is not init idtd UI 0IILI-.d lilt s IllM ( inon 1044 PROPOSED USE OF BUILDING I Business and Professions Code) �r��r77777 ~I I CONSTRU(TION L LNDING AGLN(It 1 hertby all Iran that thtrL is a conmiuttion Itndme leulk) lilt the perlormantt of the wolf for nhath till% pLln1(t Is asuaLd (Sec 3097 (Iv C ) I PROPOSED MAX OCC Lender s Name gPPLIC T(pHINTI TEL NO Lenders AddrtssADDRESS j. certify that I have mad this apphtatlon and statL til 11 111L above Information as LorrLLI I agrLe to Lonlply with all(ounty I PERMIT FEE I ordinances and State laws relating to building Comtnattaon laid G — q�a6s hereby authonre representatiles of that Count) a) entLI upon ISSUANCE FEE the above-mention propert) for lnspetuon pur1xi%A s �) I V TOTAL FEE /� I SCC REVERSE FOR EXPLANATORY LANGUAGE 10 Slgnat of PermlttLe- [lite I 444 ( ) WORKERS'COMPENSATION DECLARATION 20003DPW12/90 MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION utsure,or a certificate of Workers'Compensation Insurance,or - (� I a Certified copy thereof(Sec 3800, Lab C) Policy No Company FOR APPLICANT TO FILL IN TN. ILDING /� Rd p BUILDING DDRE s DRESS 9680 LOW or A ,5Ci RSC HCertified copy is hereby furnished �58O wer A JS4 R CALITY Certified copy is filed with the county building Inspection tilt-, ZIP n ( department 1 eYYI 10/,. Cir C� q l 7 SL7AREST Rem le 01,TZ i31 V OSS ST C:, l Date ` Applicant SIZE OF L NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE7 ROCESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS c22 0�7 S 1 CONST TRACT 6 BLOCK LOT NO O ( I COMPENSATION INSURANCE 2O MAP HIGHWAY fV NO (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved ASSESSOR MAP BVK PAGE PARCEL USE ZONE SPECIAL CONDITIONS 9 by the permit is for one hundred dollars ($100) or less) 2S 2 001 D 6 1 I I I certify that in the performance of the work for which this _ ywner T L NO 0 permit s issued I shall not employ any person In any manner W ' �t t a m SLe SG h C 418 2J3 47F's-� W so as to become subject to the Workers Compensation Laws ADDRESS �- 1/,A De (�i OCCUPANCY GROUP Z ( Date Applicant c1T a�� zIP — NOTICE TO APPLICANT If after making this Certificate d u n" PliSA ��a gl e,3o OCCUPANT LOAD of Exemption you should become subject to the Workers Compensation provisions of the Labor Code you must forthwith APPLICATION FOR EXIT HARDWARE ( I comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No ❑ revoked LICENSED CONTRACTORS DECLARATION I� Spec Knowl ❑ OCCUPANCY INSPECTION[,3 Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT❑ (LIST ITEMS BELOW) I ) 9(commencing with Section 7000)of Division 3 of the Business ameot 5s ess NO OF EXITS and Professions Code and my license is in full force and effect PARKING REQ D DPROVIDED D I License Number Lic Class t�t.4 Q� � SPACES t I Contractor Date LIMITED TIME USE I ❑ I am exempt from the licensing requirements as I am aDATE DATE licensed architect or a registered professional engineer FROM To t` I acting in my professional capacity(Section 7051,Business EXISTING BLDG q3O 5(� t�E OF No OF INSPECTOR S and Professions Code) / / F STORIES SIGNATURE. PRESENT USE OF BUILDING C O irl m e re I q Lrc or Reg No Date FINAL APPROVAL HOME OWNER-BUILDER DECLARATION NO OFEXISTING BUILDINGS i ON LOT AND USE I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 70315 Business and ( Professions Code) NPOa PAES RKING ROVIDED I ❑ I as owner of the property will do the work and the structure is not intended or offered for sale(Section 7044 1 PROPOSED USE OF BUILDING Business and Professions Code) t I I i CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ( I (Sec 3097,Civ C) POSED MAX OC fl V G i Lender's Name Ai 1(1,z :�q-C�TEL NQ. Lenders Address I certify that I have read this application and state that th X57 'Ca AVQ S i- MUn 7'CA 9173 ( I above information is correct I p 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 { i •i ,� the above-mentioned property for inspection purposes TOTAL FEE % caUL,. I&uc, 4�oa SEE REVERSE FOR EXPLANATORY LANGUAGE rI 5a n im-of PermitteeJ Date UURkERS COMPENSATION DECLARATION 20io0s3DF"12(so MISCELLANEOUS APPLICATION 4 ! 1 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 InsuranLI, or !1 a certified copv thereof(Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN TdUILbIN2'15go LDW o$ W AD j El Certified ADDRESS ADDRESS V Certified cops is hereby furnished 2 USP AY LOCAJTY SSA- Rp ❑ Certified copv is filed with the county building inspection CITY ZIP NEAREST department :FE-MeLEt( /y ur qilgp CROSS ST ) j Date Applicant _ SIZE OF LOT Q NO OF BLDGS INOOW ON LOT DIST R r Np GRQ�1P TYP �� CESSED BY CERTIFICATE OF EXEMPTION FROM WORKERS �/fi d f{ CONST// i ( COMPENSATION INSURANCE TRACT BLOCK LOT N /b/ �� MAP HIGHWAY NO .CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work in\Dred ASSESSOR MAP BOOK PAGE PARCEL USEZONE rIALCONDITIONS I b% the permit is for one hundred dollars (S 100) or less) OWNER ELN 1 r 1 certif% that in the performance of the work for which th1. permit is Issued I shall not employ am personin am manner ` Property W I L-I 19 a C El 23��6 - so as to become subject to the Workers Compensation Laus i ADDRESSO OCCUPANCY GROUP i Date Applicant _ Ci ZIP 910 NOTICE TO APPLICANT If after making this Certif.c ate a OCCUPANT LOAD of Exemption %ou should become subject to the Wo•kers 9 APPLICATION FOR EXIT HARDWARE I Compensation pro-tisionsot the Labor Code \ou must fortimid j l compl% with such pro kions or this permit shall be de.me0 TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑ reg ol.ed LICENSED CONTR ACTORS DECLARATION OCCUPANCY INSPECTION f9 Panic Devices ❑ j I Itereb% art irm that I im licenced under prrn kions of Chapter SAFET\ PERMIT )LIST ITEMS BELOW) NO OF EXITS I Q(commencing with Section 70001 of Di%lsion 3 of the Buslnesc El and Professions Code and ms licence 1s in full force and e.-fect E License Number LIC CIdSS SPACES REQ D 1 PROVIDED 1 iI LIMITED TIME USE Contractor Date I + DATE DATE 1 e ❑ I am exempt from the licensing requlrementc as I '^i a FROM TO licensed architect or a registered professional engineer INSPECTOR 5 I j acting in 1m professional CapaClts (Section 7011 Business SIZE OF ! 1 V 1 NO OF SIGNATURE ns I and Professions Code) EXISTING BLDG b STORIES LIC or Reg No Date PRESENT USE OF BUILDING FItdAL APPROVAL I i HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE � 1 Itereb) affirm that I am exempt from the Contractors License Lax for the following reason (Section 70315 Business and 11 Fmfessions Code) NO PARKING 37 ElI as owner of the proper[) well do the wort anJ the SPACES PROVIDED j structure 1s not intended or offered for sale(Section 1944X PROPOSED USE OF BUILDING ' I Business and Professions Code) ) CONSTRUCTION LENDING AGENCI I hereby affirm that there is a construction lending agenc, fol the performance of the wort, for which this permit 1s lssuecl (Sec 3097 Civ C) PROPOSED MAX OCC L Lender S Name __ APPLICANT(PRINT) ELN C bu 6 7S-A& Lenders Address ADDRESS I certif% that I have read this application and state that tha 0-a P6_Na 2 J HOP FICA- ( 07- above information is correct 1 agree to comply with all Co inti PERMIT FEE ordinances and State laws relating to building construction and i hereby authorize representatives of this Count) to enter 1 por ISSUANCE FEE ! the above-mentioned property for Inspection purposes TOTAL FEE m 1 c I % ( l(A-f 1U &UuF,f(/ I/Q ou SEE RE%ERSE FOR EXPLANATORY LANGUAGE I- W Signature of Permltiee Dat L I