HomeMy Public PortalAbout9614 LOWER AZUSA RD_Miscellaneous__ WORKERS'COMPENSATION DECLARATIONCE 875(1 1 84) M I SC E L N 6�0 - APPLICATION
I hereby afficert that I have a certificate of consent self COUNTY OF LOS ANC kV BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or
a c6rtified copy thergof(Sec 3800,Lab C)
Policy No CompanyFOR APPLICANT TO FILL IN BUILDING /
ADDRESS
1
Certified copy is hereby furnishedBUILDING 1 LOCALITY
ADDRESS I �.
Certified copy 13 filed with the county building inspection LOCALITY �•�/- NEAREST
department / CROSS ST
Date Applicant NEAREST �� `� ` DIST IC O OUP TYPE P CESSED BY
CROSS ST ( 6r ,�{/ �i CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a (�
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY
STATE MAJOR SECOND LOCAL
/��, NO OR SLOGS
e0 (CIRCLE) '
is section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
(Th
by the permit is for one hundred dollars ($100) or lest:) _
USE OR
SIZE OR LOT �
I certify that in the performance of the work for which this EXISTING BLDG f o
permit is issued,I shall not employ any person in any manner OWNER011P
so as to become subject to the Workers' Compensation Laws MAIL i OCCUPANCY GROUP � o
" O G V
Date Applicant
ESSXTELcant _
NOTICE TO APPLICANT If,after making this Certificate of CITY NO �j�lOCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth-_ APPLICATION rCR EXIT HARDWARE
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 19
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO OF EXITS
ness and Professions Code,and my license is in full force and
effect 0.1(YI a of GCS%/1)`pss r SPACES RuQ,D PROVIDED
License Number Lic Class i C f; LIMITED TIME USE
Contractor Date ' DATE DATA '
0 I am exempt from the licensing requirements as I am a PROM TO
licensed architect or a registered professional engineer SIZE of No of / INSPECTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG HroRIEH ` HI ATURE
mess and Professions Code) PRESENT USE OR BUILDING FINAL APPRRVAL
Lic or Reg No Date
NO
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's _ VVV e
License Law for the following reason (Section 70315, Bun- l�l � i v� J�g`
ness and Professions Code) I NO PARKING -- - {
I, as owner of the property, will do the work and the SPACES PROVIDED + ` - 1 '4�l
structure is not intended or offered for sale (Section
9044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY PROPOSED USE OR BUILDING r
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 _
PROPOSED MAX OCC
Lender's Address
I certify that I have read this application and state that the PERMIT FEE - DU ,
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, °
and hereby authorize repr tives of this County to enter TOTAL FEE a� W
upon the abo entione prope for spection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
3
Signature of Permittee at