HomeMy Public PortalAbout9606 LOWER AZUSA RD_Miscellaneous__ ( , WORKERS'COMPENSATION DECLARATION 76W" r,y� MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION
"insum or a certificate of WdrUrs'Compensation Insurance,or
{ , a eerhf"red copy thereof(Sef. 3800, Lab.C.)-
Policy No. Company 1 UZM ADORES FOR APPLICANT TO FILL IN BUILDING
ADDRESS
1 ® Certified copy is hereby furtushed. (6O Lower o` L&ALITY
( EST
Certified copy is filed with the county bu)ldmg inspection erry ZIP
' I department •t COL f 'O CROSS ST ?-
Date ' ° Applicant gIZE OF LOT NO OF BI DGS NOW LOT DISTRICT NO GROUP TYPE PROCESSED BY
CONST
�.
CERTIFICATE OF EXEMPTION FROM WORKERS TRACT BLOCK LOT NO O
( , COMPENSATION INSURANCE ,KAP �) STATE MAJOR SECOND LOCAL V
(1Tits section need not be completed If the pork involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
( L certify that in the performance of the work for which this C► r TEL NO
I permit is issued. I shall not employ any person in any manne
1 so as to become subject to the Workers Compensation Laws. AtwREs �3 +� OCCUPANCY GROUP Z
( , Date Applicant elnrZIP
NOTICE TO APPLICANT If, after making this Certificate 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 US6❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑
revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION(I Panic Devices ❑
I I hereby affirm that I am hcerwd under provisions of Chapter SAFETY PERMIT❑ (UST ITEMS BELOW) NO OF Exirs
.9(commencing with Section 7000)of Division 3 of the Busines 9m ot Busluessand Professions Code and my license is in full force and effec
PARKINCZSG REWD D PROVIDED D
1 License Number Lie Class SPP`
( I I Contractor Date UMITED TIME USE
i ❑
DATE DATE
FROM I am exempt from the licensing requirements as I am a TO
' licensed architect or a registered professional engineer
acting in my professional capacity(Section 7051,Business SIZE OF No of INSPECTO
RIS
( and Professions Code) EXISTING BLDG STORIE,, SIGMA E.
Lic or Reg.No. Date PRESENT USE OF BUILDING FINAL APPROVAL , — 2e Ofill
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
I ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 70315. Business and
{ Professions Code) NO PARKING
, ❑ I, as owner of the property will do the work and SPACES PROVIDED
structure is not intended or offered for sale(Section 7 _ POSED USE OF BUILDING
Business and Professions Code)
( IRe adly
i CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for Gs sat
the performance of the work for which this permit is issued
{ I (Sec 3097,Civ C) PROPOSED MAX OCC
Lender's Name APPLICANT r ) TEL NO
Lender's Address ADDRESS gF
j 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
F I ordinances and State laws relating to building construction,and
I hereby authonae resentatives of this County to enter upon ISSUANCE FEE
the above-men a roperty for inspection purposes. -
TOTAL FEE
X SEE REVERSE FOR EXPLANATORY LANGUAGE
t Signature of Permittee Date