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Home My Public Portal About4700 D MILLER DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) M I SC E L LA N EO U S APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BAUILDIDNG DRESS M Certified copy is hereby furnished. BDDRESS UILDING UO AocwLITY Certified copy is filed with the county building inspection LOCALITY /� ` �, CROSS T department. G y 7 Date Applicant NEAREST DISTRICT NO. GROUP TYPE P CESSED BY CROSS ST. '� G /� CONST. y� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL D COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLE) NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER 01f ) ® 5� so as to become subject to the Workers' Compensation Laws. a OCCUPANCY GROUP MAIL Date Applicant ADDRESS � , / `� W d TEL' OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY �� M p/v �(i NO. (. �1� QCy613 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 oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know[. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM( (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 _ p effect. oat-' It Sf S • PARKING RE WO PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE _ PROM: TOC�� ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OFNO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TORE / � 93 iness and Professions Code). ! . +i—!i' 1 Ii PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE 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): NO. PARKING 0 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 BUUI"LDING I Hereby affirm that there is a construction lending agency�'��V (7 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 have read this application and state that the UT? above information is correct.I agree to comply with all County ISSUANCE FEE .ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter roTAL FEE upon the ab -mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _-2 SfOKure of Permittee U f Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION 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 copy thereof(Sec.3800,Lab.C.). —� Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS f Certified copy is hereby furnished. BUILDING �� 2 l �� LOCALITY ADDRESS yy Certified copy is filed with the county building inspection LOCALITY - NEAREST department. ))�- ��]]�l� L CROSS ST. rYPE Date Applicant NEAREST CROSS STDISTRIC CONST. PR ES E BY . ,� �...J CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP Hirmi4ty STATE MAJOR CON LOCAL NO. (CIRCLE) NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOTUSE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which thiso permit is issued, I shall not employ any person in any manner OWNER 'DIF(�)�t 1 loel OW CPAI RRQ - �N� �-.s s' so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP CC ADDRES ~ Date Applicant MAIL �f �J A / W NOTICE TO APPLICANT: If, after making this Certificate of CITY��! �,� [�No4j�� Qd� OCCUPANT LOAD 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. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter NMC 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 S�r��s effect. PARKING SPACES REQ'D O PROVIDED J License Number Lic. Class — r LIMITED TIME USE Contractor Date D ATE DATE FROMI TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSSPECCTO s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IPATU iness and Professions Code). ✓/ PRESENT USE OF BUILDING New yu/ N s FINAL APPROVAL Lic.or Reg.No. Date ICY ,[J �ff HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS NOrE ON LOT ANO USE 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): NO. PARKING ° I, as owner of the property, will do the work and the SPACES PROVIDED 04?6 AM 9-04 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF HUILDIN I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is N , issued(Sec. 3097,Civ.Q. Lender's Name f —_ PROPOSED MAX. OCC. Lender's Address PERMIT FEE � I certify that I have read this application and state that the ,.J above informa ' n is correct.I agree to comply with all County ISSUANCE FEE ordinan and tate laws re ng to building construction, and reby thorize re rese fives of this County to enter TOTAL FEE UP96 the ove-menti ed p er nspecti urpose EE REVERSE FOR EXPLANATORY LANGUAGE p _!�*�er kitt� Date "WQRKERS'COMPENSATION DECLARATION 76M444 _ _ CE 875(11-84) M ISCELLANE&US APPLICATION 1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES ��BUILDING AND SAFETY DIVISION Insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING g7V p A/4 R D -Y ,-�1 ADDRESS / Certified copy is hereby furnished. I j SUIL61NG O 0 A4-1!/e _ LLOCALITY T Ire o/ V X14 .wDDR.Eas Certified copy is filed with the county building inspection_ -•,;OCALITY NEAREST Zo ti/Z Zv�/1 department. & , ____ PrYY! I? 9 Q. CROSS ST. Date Applicant `yl NEAREST - t,'ytl n DISTRICT NO. ORO��1ttP TYPE CE59ED BY CRO SS ST. Lo vV L^ / 2-u �I V`K.r �} CONST.-J/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALap COMPENSATION INSURANCE DESCRIPTION TOT NO. BLOCK MAP NIOHWAY STATE MAJOR SECOND LOCAL NO. (CIRCLs) NO.OF BLDOS. (Tills 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.) usic OF I certify that in the performance of the work for which thisr SIZE OF LOT E- XISTING BLDG. permit is issued, 1 subject not employ any person in any mLaws. 'C3*-r KR ;building ® =' so as to become subject to the Workers Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS Z b N• 154LDW)A1 A r- Date Applicant j D. NOTICE TO APPLICANT: If, after making this Certificate of CITY• 15L M pint No. 4C �3 v O]g OCCUPANT LOAD vi Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you mtmst forth- El comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. ❑ I RTNSF.D CONTRAC:'I'ORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I and 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 frill force a '- -' t-- ---�� effect. r` .X_Name af:�bu S-ir eSs- PARKING REq-D ,N'OROVIDEO r' ' C �1/ SPACES u License Number Lic. Class � ✓^ SG'V S LIMITED TIM 1.1 F,, Contractor_ Date OATHii.�� jj``lj�[ DATE FROM: T.?506 I• P• i 1 am exempt from the licensing requirements as 1 am a INSPECTOR s licensed architect or a registered professional engineer SIZE OF F No.OF SIGNATURE acting in my professional capacity (Section 7051, Bus EXISTING BLDG. 3(6,70 STORIES r inessand ProfcssionsCode)' FINAL APPROVAL /�� Q �� PRESENT USE OF BUILDING h e Lic.or Reg.No._____ _Date n 11 :Q�] immi,.OWNP:11-13111LDER DECLARATION NO. OF EXISTING BUILDINGS 'a 1V, ON LOT AND USX 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- Jf" nas and Professions Code): NO. PARKING 1, 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 I hereby affirm that there is a construction lending agency For the perforniance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX.OCC. Lender's Address PERMIT FEE 25,001 certify that 1 have read this application and stale that the shove information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, i.Id hereby authorize representatives of this County to enter TOTAL FEE 25.001 upon th above-mentioned properly for insp ct�purposes. }C1�. � � / SEE REVERSE FOR EXPLANATORY LANGUAGE XX.=" WORKERS'COMPENSATION DECLARATION M I SC�_I LA N EO U S APPLICATION e_ ICE CE 875(11 84)875 It , I ] affirm that 1 have a certificate of consent tself I COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION A insureure,, o or a certificate of Workers'Compensation Insurance, e,or r a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN ADDR NG.�{700 le d9 ,,I ADDRESS Certified copy is hereby furnished. BUILDING f/ /�" `/ / z1 LO CA LIT f LTJ t ❑ XX ADDRESS 7 � /•tet l�` —/ Certified copy is fried with the county building irppection LOCALITY NEAREST department. x)[ ceoss ST. Date Applicant' �^ NEAREST L 7_IZn kd DISTRICT NO. GR UP CONSITYPEV CESSED BY CROSS SITGA l�6/� �O(j CERTIFICATE OF EXEMfiTI�N FROM WORKERS' LEGAL o COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAYNo. OF STATE MAJOR SECOND LOCAL NO. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT S. 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, n permit is issued,1 shall not employ any person in any manneXX OWNER of building so as to11; co a subject to the 1 ers'Compensatign aws. MAIL ®®�IJ [l OCCUPANCY GROUP ADDRESS /6'+IN"l. `, r- Date Applicant LL NOTICE T APPLICANT: If, ter a g this ertificate of CITY �,� 7ha� C✓- No� (Y OCCUPANT LOAD Exemption, you sliould become s ject 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. � Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) a 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 anix effect. , Name of business PARKING 1 SPACES REq'D D PROVIDED D License Number Lic. Class S iN ��N of S/�/ �� ' LIMITED TIME USE Contractor Date a DATE DATE I am exempt from the licensing requirements as I am a .�/N d �'V �iQN�, /0"U4 '(, FROMI TO: licensed architect or a registered professional engineer SIZE OF NO.OR INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE iness and Professions Code). FINAL APPROVAL ,/o�, PRESENT USE OR BUILDING 66 Lic.or Reg.No. Date HOME.OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS gv i ON LOT AND USE I hereby affirm that I am exempt from the Contractor's "yjA_ License law for the following reason (Section 7031.5, 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 PROPOSED USE OF BUILDING 1 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.). -:,r IwJ tet Lender's Name �` o PROPOSED MAX. Lender's Address _-M '+ PERMIT FEE 1 certify that 1 have read this application and state that the 95.00 above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives 's-County to enter TOTAL FEE 25.00 •' upon the above-mentioned pro or inspection purpose. I =L SEE REVERSE FOR EXPLANATORY LANGUAGE XX XX `f ry Signature of Permittee date