HomeMy Public PortalAbout9604 LOWER AZUSA RD_Miscellaneous__ A WORKERS COMPENSATION DECLARATION CE 875(1 1 84) MISCELLANEOUS APPLICATION D
I hereby affirm cert that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure i or a certificate of Workers Compensation Insurance or
a certf-''Nd copal thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS (�
FiCertified copy is hereby furnishedBUILDING O e ZuSGI 0
ADDRESS LOCALITY
Certified copy is filed with the county building inspection NEAREST
department LOCALITY a C_4 V CROSS ST =(,tAvec: G! ['G 0,0
Date Applicant NEAREST e CROSS ST G DISTR I,T� RQuCONSITY T CE336D BY
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL ':
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO (CIRCLE)
NO OF BLD65
(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) usr OF
SIZE OF LOT EXISTING BLDG
I certify that in the performance of the work for which this o
permit is issued I shall not employ any person in any manner ZOWNER 0 f B u i 1 d 1 n 0 y
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP 12i] oDate Applicant ADDRESS QLowe t7d W
NOTICE TO APPLICANT If after making this Certificate of CITY Cy� .1.1 OCCUPANT LOAD H
Exemption you should become subject to the Workers z
Compensation provisions of the Labor Code you must forth AP LICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER US6GEOLOGY INSPECTION
deemed revoked C] ❑ 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 Dmsion 3 of the Busi- - NO of EXITS
ness and Professions Code and my license is in full force and
effect Name of Business PPAC68 REQ DARKING
SD PROVIDBD
License Number Lic Class
LIMITED TIME USE
Contractor Date OATH DATE
ElI am exempt from the licensing requirements as I am a FROM TO
licensed architect or a registered professional engweer SIZE OF NO OF INSPECTOR S
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL
Lic or Reg No Date RESENT USE OR BUILDING
Vacant N
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGSO FEE
ON LOT AND US6 � h
I hereby affirm that I am exempt from the Contractors n
License Law for the following reason (Section 70315 Busi //�� J 0000-0001 11f 08/9-1
ness and Professions Code) NO PARKING �`Fv1 1 lei 4 4,'.1
❑ I as owner of the property will do the work and the SPACES PROVIDED (( ' M '1
structure is not intended or offered for sale (Section
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency e 0,112-176V
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lender s Name
PROPOSED MAX OCG
Lender s Address
I certify that I have read this application and state that the PERMIT FEE 25 . 00
above information is correct I agree to comply with all County ISSUANCE FEE
drdinances and State laws relating to building construction
and hereby authorize representatives of this County to enter TOTAL FEE 25 00
upon the bove�one�prop ty for inspection purposes
// r SEE REVERSE FOR EXPLANATORY LANGUAGE
Si a ure of ermittee Date