HomeMy Public PortalAbout9621 LOWER AZUSA RD_Miscellaneous__ reORKERS'COMPENSATION DECLARATION CE 875
(2 80) MISCELLANEOUS APPLICATION
hereby affirm that I have certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'
rs'Compensation Insurance,
e,or
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING r
ADDRESS
Certified copy ishereby furnished LOCALITY
QADDRESS DRH83
Certified copy is filed with the county building inspection
department OCALITY , � y CROSS ST
Date Applicant- ARHST t DISTRICT NO G P TYPE PROCB SED Y
ROSS ST ev se
CONST 1
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v {l �I
DESCRIPTION LOT NO BLOCK
COMPENSATION INSURANCE NOP N16MV�Ar }
(CIRCLE) STATE MAJOR 86C0 LOCAL d
NO OF BLD68
(This Section need not be completed if the WOIIC mVO1Ved TRACT NOW ON LOT U86 O 6 PECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less)
$�0
812E O LOT 971'T' � BLDG 10
I certify that In the performance of the work for which this / p
permit Is Issued, I shall not employ any person in any manner WNE
so as to become subject to the Workers' Compensation LawsL OCCUPANCY GROUP W
ADDRE I d
Date Applicant Z
NOTICE TO APPLICANT If, after making this Certificate of clrY NH OCCUPANT LOAD
Exemption, you should become subject to the Workers' I EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTJq
ION
deemed revoked ❑ ❑ NO Spec Knowl ❑
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST s BELO o of Extrs a
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and ING
effect R.W. D PROVIDED D
SPACES
License Number Lic Class
LIMITED TIME USE
Contractor Date Are DATE
a N ro
I am exempt from the licensing requirements as am a
licensed architect or a registered professional a gain
E No Ir1ePHcroR'E
acting in my professional capacity (Section 70 1, Bus- IN BL G IES 9IGNATURN
ess and Professions Code) FINAL APPROVAL
m
BN U86 OF BUILDING SSI
Lic or Reg No Date /
X
HWE OWNER BUILDER DECLARATION No 6XISTIN
ON LOOT AND ILOINGS cC-
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busi-
ness and Professions Code)
SPACES PROVIDED
F1 I, as owner of the property, will do the work and the # • • • • 8 8
structure is not Intended or offered for sale (Section
7044,Business and Professions Code) PO • • • e e • • 2
SED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency /T /1% 04,25-85
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 PERMIT FEE
I certify that I ha v r d is a lication an to that the
above informatio c re IS to Comw all County ISSUANCE FEE
ordinances and to la s r g to b d construction, TOTAL FEE
and here a e re atives o County to enter
upon eb entio roperty mspec1%pM_aurposes SEE REVERSE FOR EXPLANATORY LANGUAGE
ignatu of Pe mitte D e