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Home My Public Portal About9612 LOWER AZUSA RD_Miscellaneous__ r , ! WORKERS'COMPENSATION DECLARATION; Moo oo83DPw/2,80 MISCELLANEOUS APPLICA`I•'ION r }I I hereby affirm that I have a certificate of consent'to self COUNTY OF LOS-ANGELES BUILDING AND SAFETY DIVISION insure,or or a certificate of Wdrkers'Compensation Insurance or - w 1 a eertlfted copy thereof(get 3800, Lab.C} � t Policy No. GOmpany FOR APPLICANT TO FILL IN BUILDING ' BUILDING ADORES ADDRESS I ® Certified copy is hereby"shed. k Z-z,,i 2 LOCAurif i Certified copy is filed with the county building inspection CUX ZIP EARdepartment P�L (!J TV 7�0 CROSS SST Date ' ° Applicant SIZE OF LOT NO OF BLDGS NqWO LOT DISTRICT NO GROUP TYPE PROCESSED BY d CONST CERTIFICATE OF EXEMPTION FROM WORKERS' TRper BLOCK LOT No O ( I COMPENSATION INSURANCE ►� woKwAY V NO ICIRCL[I STATE MAJOR SECOND t.00AL (This section need not be completed if the work Involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONE SPECIAL CONDITIONS CG by the permit is for one hundred dollars ($100) or less.) e TEL NO ( I certify that in the performance of the work for which this A ry 9 I permit is issued. I shall not employ any person In any manner p, so as to become subject to the Workers Compensation Laws. AD Ess OX OCCUPANCY GROUP Z ( , Date Applicant PI C!� 'IP q�r�� NOTICE TO APPLICANT If after making this Certificate Le ` < OCCUPANT LOAD of Exemption you should become subject to the Workers' APPUCAT10N FOR Compensation provisions of the Labor Code,you must forthwith EXIT HARDWARE comply with such provisions or'this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑ ( 1 revoked CJ Panic Devices El CONTRACTORS DECLARATION OCCUPANCY INSPECTION j I hereby affirm that I am licensed under provisions of Chapter X lam sAFETY PERMIT❑ (LIST(rims BELOW) •Cl t 1 9(commencing with Section 7000)of Division 3 of the Business O 178 e88 No OF EXITS and Professions Code and my license is in full force and effect PARKING REG'DO PROVIDED O License Number Lie Class t7s� SPACES t 1 I Contractor Date LIMITED TIME USE ❑ I am exempt from the licensing requirements as I am a FROM DATE TO DATE licensed architect or a registered professional engineer acting in my professional capacity(Section 7051,Business SIZE OF NO OF INSPECTOR'S and Professions Code) EXISTING BLDG STORIES SIGNATURE. Lic or Reg Na - Date PRESENT USE OF BUILDING FINAL APPROVAL L ' 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 1 ❑ I as owner of the property, will do the work and the ACES PROVIDED structure is not intended or offered for sale(Section 7044,1PROPOSED USE OF BUILDING Business and Professions Code) CDC IZ L0440F CONSTRUCTION LENDING AGENCY t I I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ' t i ' (Sec.3097,Civ C) PROPOSED MAX OCC. Lender's Name APPIJC ) R �� TEL NO leir Lender's Address A DR S ( I certify that I have read this application and state that the A- ANITh 10eler CI7.V &MO above information is correct I agree to comply with all County PERM,FEE I ordinances and State laws relating to building construction,and - I hereby authorize representatives of this County to enter upon ISSUANCE FEE / the ab e-ment'ioned property for inspection purposes ' TOTAL FEE - % SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o rm ee Date