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Home My Public Portal About9608 LOWER AZUSA RD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGBUILDING AND SAFETY DIVISION insure, or a certificate of Wdrkers'Compensation Insurance,or ,� a certifie..copy the`eof(Sec 3800,Lab C) 'fl Policy No Company FOR APPLICANT TO FILL IN BUILDING n ADDRESS C/ Certified copy is hereby furnishedUILDIN6 )In QJ e �S LOCALITY DDRESS ElCertified copy is filed with the county building inspection Nf LOCALITY NEAREST department CROSS Sr 67 Date Applicant NEAREST DISTRICT N UP TYPE:]�E CUSSED BY L��(• CONS CROSSST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �X COMPENSATION INSURANCE DESCRIPTION I LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO OR BLDGS No (CIRCLe) (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.) SIZE OR LOT USE T -� I certify that in the performance of the work for which this EXISTING BLDG o permit is issued,I shall not employ any person in any manner OWNER Al 5-31 so as to become subject to the Workers' Compensation Laws �a m MAIL OCCUPANCY GROUP Date Applicant )C ADDRESS 96 O 2 e s I17 NOTICE TO APPLICANT If,after making this Certificate of CITY e i NOL OCCUPANT LOAD Exemption, you should become subject the WorkersAPPLICATION 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 - 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT (LIST ITEMS BELOW) - NO OF EXITS ness and Professions Code,and my license is in full force and / 1 effect D 7 / PARKIN6REQ'D PROVIDED � SPACES 11��JJ License Number Lic Class LIMITED TIME USE Contractor Date DATE OATH I am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer SIZE OF No OF INSPU o 'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES mess and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING Lic or Reg No Date Ph a 3 HOME OWNER-BUILDER DECLARATION No OF 6XID STING BUILDINGS 'vl �1 �t�7 1304M-001-11A�/,I 191t ON LOT ANUSE 1[I:�t�i�+ I hereby affirm that I am exempt from the Contractor's — 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 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY pROPOBUD USE OR BUILDING I 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 Lender's Address I certify that I have read this application and state that the PERMIT FEE oo PROPOSED MAX OCC above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authoriz representat a of this County to enter TOTAL FEE upon the abov oned grope or inspecti purR s _ VERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date