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Home My Public Portal About4700 A MILLER DR_Miscellaneous__ KED'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 I `hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified cof y thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL BUILDING ^ ,y�) ADDRESS FiCertified copy is hereby furnished. BUILDING _ ADDRESS 7t)o Millet Z j),7 [J /T LOCALITY ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. -&. IfUra CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP ITYPE PROCESSED BY ST. CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' CROLEGAL O #� !r1'� � �«"�'"�� COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL N NO. OF BLDGS O. (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.) usE of I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. permit is issued, I shall not employ any person in any manner OWNS j�j 0;S 5A;1. y so as to become subject to the Workers' Compensation Laws. fMAIL OCCUPANCY GROUP Z9:1 Date Applicant AD DRESSla6S lr / �4'(. v NOTICE TO APPLICANT: If, after making this Certificate of CITY �o '4,�_ No� /ll —Q�� OCCUPANT LOAD N LL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PER ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- I NO. OF EXITS ness and Professions Code,and my license is in full force and 1- effect. G Q r- PARKING I�, SPACES REq'D D PROVIDED D License Number Lic. Class IvO o--j m o- U LIMITED TIME USE Contractor Date OATH DA TH 0 1 am exempt from the licensing requirements as I am a I FROM: TO: licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. `?Q ,S1� STORIES l SIGNATURt iness and Professions Code). ala ` 1 FINAL APPROVAL Kli—I �^9� PRESENT USE OF BUILDING b Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDING ON LOT AND USE I hereby affirm that I am exempt from the Contractor's :I_i�.(_i:i_ii ti' f 4. License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING r— ?L.i ; ='M s'i-- ❑ 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 PROPOSED USE OF BUILDING o�[�� `ry G 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.Q.Lender's Name PROPOSED MAX. OCG. O.A0 ender's AddressPERMIT FEE oQ •(p, I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEES ordinances and State laws relating to building construction, 171 d hereby authorize representatives of this County to enter TOTAL.FEE pon the mentioned pro pe for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date • WORkERS'COMPENSATION DECLARATION 76M444 CE 875(11-84) M ISCELLANEO'US /APPLICATION {� I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION LI insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN ADD BUILDING ss Certified copy is hereby furnished. BUILDING A r( LOCALITY ADDRESS ElCertified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE OCESSED BY CROSS ST. ��/jam CON CERTIFICATE OF EXEMPTION FROM WORKERS' Ne- LEGAL 'D� COMPENSATION INSURANCE DESCRIPTION LOT NO. IM BLOCK MAP HIC Nw Av STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF BLDGS. (This section need not be completed if the work involved TRACTILr—fi NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) SIZE OF LOT 27 EXISTINNAP USE of 'b a I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL 4,11 OCCUPANCY GROUP Date Applicant ADDRESS u0 C) L~�LI NOTICE TO APPLICANT: If,after making this Certificate of clrY NE d C� — OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- ❑ with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION deemed revoked. El ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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. PARKING SPACES REQ'D O PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE[ DATE I am exempt from the licensing requirements as I am a FROM: TO: - licensed architect or a registered professional engineer SIZE OF //�� NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. v STORIES SIG ATURE 2 V(�/ iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDI1,IGS ON LOT AND U E �•N r.-rf"I.. I hereby affirm that I am exempt from the Contractor's `'tl-L '-(=(U l Yl+ :'i''i'1 41 License Law for the following reason (Section 7031.5, Busi- _;y ness and Professions Code): NO. PARKIN U I I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section U 7044,Business and Professions Code). PROPOSED USE OF BUILDING h CONSTRUCTION LENDING AGENCY 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 above information is correct.I agree to comply with all County ISSUANCE FEE ordinances a State laws relating to building construction, and hereby thorize repres tatives of this County to enter TOTAL FEE a5� upon t ve me io d p for inspecti n purposes. •7e� �(. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig a ure of Per itt Date