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Home My Public Portal About9590 LOWER AZUSA RD_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 875(2 80) 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 C) Policy No Company FOR APPLICANTTO FILL IN BUILDING ❑ ADDRESS or Certified copy is hereby furnished BUILDIN OC ALITY ADDRESS Certified copy Is filed with the county building inspection NEAREST department I LOCALITY CROSS ST Date Applicant EAREST DISTRICT NO GROUP TYPE JP SED BY 1.0 CROSS ST O CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL COMPENSATION INSURANCE DESCRIPTION Lor No BLOCK MAP IGHWAY NO (CIRCLE) STATE MAJOR SECOND LOCAL d ( completed e work inTRACT NOW ONvolved NO OF BLLOTT USE NE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE OF / V I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG permit is issued I shall not employ any person in any manner Q NER H so as to become subject to the Workers Compensation Laws AIL y Cd r� OCCUPANCY GROUP �1 .W AD ES d J AlCL Date Applicant DR � c ' W NOTICE TO APPLICANT If after making this Certificate of Irr�s' �/6 noLo7/3 �� B OCCUPANT LOAD z 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 USE GEOLOGY INSPECTION deemed revoked O NOSpec KnOWI El Panic Devices LICENSED CONTRACTORS DECLARATION I 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 Bust ness and Professions Code and my license Is in full force and PARKING effect REQ OF SPACES PROVIDED D i License Number LIc-Class LIMITED TIME USE Contractor i Date DATE DATE ^. FROM TO U 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 iness and Professions Code) PRESENT USE OF BUILDING FINAL APPROVALs�,.�� •�j'�.t_-�; 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 Contractors License Law for the following reason (Section 7031 5 Bust ness and Professions Code) NO PARKING SPACES PROVIDED { I as owner of the property will do the work and the ;2 1 7 56 A structure is not intended or offered for sale (Section t 7044 Business and Professions Code) # • • • • 8 8 PROPOSED USE OF BUILDING 1 CONSTRUCTION LENDING AGENCY - I• • • • • • • z I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 0 5061-83 issued(Sec 3097 Civ C) Lender s Name PROPOSED MAX OCC Lender s Address PERMIT FEE 1 I certify that 1 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 byauthorize representatives of this County to enter S. upon e a ve mentioned pro rty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signatu of Permittee Date 1 r .016WORIrERS COMPENSATION DECLARATION CE 875 4(2 0) 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 'fl a certified copy thereof(Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished BUILDINc/> 1 LOCALITY ❑ ADORES Certified copy is filed with the county building inspection NEAREST department LOCALITI� ' CROSS ST ` c + Date_ Applicant NEARESTff DISTRICT NPP 6 UP TYPE PROC SED BY ` CROSS ST �I/J CONST CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL a441 / J v COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP / HIGHWAY Ro / (CIRCLE) STATE MAJOR SEGO LOCAL Q, NO OF BLOGS 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) A USE cc E OF LOT EXISTITI NG BLDG v I certify that in the performance of the work for which this O permit is Issued I shall not employ any person in any mannerowNE i— so as to become subject to the Workers Compensation Laws AIL m� OCCUPANCY GROUP W AD RES N Date_Applicant #a NOTICE TO APPLICANT If after making this Certificate of So CITY nTi OCCUPANT LOAD Z Exemption you should become subject to the Workers Compensation provisions of the Labor Code you must forth ff APPLICATION OR EXIT HARDWARE with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION 1:1NO Spec Knowl ❑ deemed revoked ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 RKING effect SPACES REQ D PROVIDED License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE ❑ FROM TO I am exempt from the licensing requirements as I am >i, licensed architect or a registered professional engineer SIZE OFNo OF INSPECTOR S acting in my professional capacity (Section 7051 Bus EXIS ING BLDG STORIES SIG)NATURE iness and Professions Code) RESENT USE OF BUILDING FINAL APPROVAL O / Lic or Reg No Date HOME OWNER BUILDER DECLARATION No OF EX ON BUILDINGS ON LOT AND USE i 0 9 S 0 A I hereby affirm that I am exempt from thg Contractors # 000088 License Law for the following reason (Section 7031 5 Busi ness and Professions Code) NO PARKING SPACES PROVIDED IB S 0 S 0 S B ❑ I as owner of the property will do the work and the structure is not intended or offered for sale (Section 10,24-84 7044 Business and Professions Code) OPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is IF 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 FEE an er by authorizer sentatives of this County to enter o e above 90n,, pro t mspec I n pur os SEE REVERSE FOR EXPLANATORY LANGUAGE APs Signature of Permittee Date WORKERS COMPENSATION DECLARATION 4 CE 875(11 84) MISCELLANEOUS APPLICATION CE 87 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insifte 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 BUILDING /� 9F5 C/o ADDRESS TO Lo�✓E/2 14_Z t/5'14- RD LOCALITY Certified copy is filed with the county building inspection LOCALITY / F_m P{).F_ C cr NEAREST department CROSS ST Date Applicant 4EARIEST DISTRICT U pry/ PROCES BY CERTIFICATE OF EXEMPTION FROM WORKERS CROSSLEGAL �� '� ��' �` COMPENSATION INSURANCE DESCRIPTION I LOT NO BLOCK MAP HIGHWAY STATE MAJOR SE CON LOCAL NO (CIRCLE[) 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 C Ci permit is issued I shall not employ any person in any manner OWNER M, d s� so as to become subject to the Workers Compensation Laws AIL OCCUPANCY GROUP o Date ADDRESS b Applicant614 6 LLI NOTICE TO APPLICANT If after making this Certificate of CITY �- NOL 13,,Z _3Or'ja OCCUPANT LOAD a 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 OI this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ deemed revoked. 99 E] ❑ No Spec Knowl LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM( [] (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busy NO OF EXITS ness and Professions Code and my license is in full force and effect PARKING SPACES REQ D D PROVIDED O License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer SIZE OP NO OF 1NSP TOR S acting in my professional capacity (Section 7051 Bus (STING BLDG STORIES sl ATURIS mess and Professions Code) Iq F FINAL APPROVAL Lic or Reg No Date PRESENT USE OF BUILDING R E L F,111- FyVD HOME OWNER BUILDER DECLARATION No OF EXISTING BUILDINGS ;8 8 S ON LOT AND USE I hereby affirm that I am exempt from the Contractors o122-88 License Law for the following reason (Section 70315 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 I 7044 Business and Professions Code) y CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING �X)STI/G I hereby affirm that there is a construction lending agency Q AfV 5 Ho 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 FEEd5, 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 and hereby authorize representatives of this County to enter TOTAL FEE Out pon the above m io d property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signat a of Permittee Date