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Home My Public Portal About4700 F MILLER DR_Miscellaneous__ 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 AD DR Ess >17" Certified copy is hereby furnished. BUILDING / O� �4r 00 ADDRESS v, mw LOCALITY �. Certified copy is filed with the county building inspection • LOCALITY /► � NEAREST department. T "— C•� CROSS ST. Date Applicant NEAREST /� DISTRICT NO.]JOUP TYPE PROCESSED BY ROSS ST. �J CONST. - , CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a p` COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (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 SIZE OF LOT EXISTING BLDG. a I certify that in the performance of the work for which this dF !!iL 1S/.V6 permit is issued,I shall not employ any person in any manner OWNER � S s2 so as to become subject to the Workers' Compensation Laws. M IL r OCCUPANCY GROUP /� o DURESS t� Date Applicant I„ NOTICE TO APPLICANT: If,after making this Certificate of CITYo�' �� OCCUPANT LOAD y Exemption, you should become subject to the Workers' z 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 ❑ 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 ❑ (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 D PROVIDED D License Number Lic. Class Jer O Al Z,4 • �11t& LIMITED TIME USE Contractor Date DATE DATE ••r I am exempt from the licensing requirements as I am a FROM: TO: rA =- ... licensed architect or a registered professional engineer SIZE OF T INSPECTOR'S S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE lnessand Professions Code). FINAL APPROVAL Lic.or Reg.No. Date PRESENT USE OF BUILDING T ^ y1 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON L07 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 yJ 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 �( 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. 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 and State laws relating to building construction, O and Hereby authorize representatives of this County to enter TOTAL.FEE ad- upon the above-mentioned property for inspection purposes. `{� � SEE REVERSE FOR EXPLANATORY LANGUAGE 4c I Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 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 thereofiSec.3800,Lab.Q. Policy No. C, Company FOR APPLICANT TO FILL IN fN DING //�� An ( �p,(r• q y. ,t 1 ESS �. ❑ CeItl£led Copy 15 heIeby fl1InlSlled. ADDRESS Y o D M-1 &1 M)1 1 ve OI11 T, LITY Certified copy is filed with the county building inspection LOCALITY Edepartment. Teel a G/'Y s sr. Date Applicant NEAREST DISTRICT NO. GROUP TYPE CESSED BY CROSS ST. �D e CONST,0f CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �j COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF BLDGS. No. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONIISPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF ^ SIZE OF LOT EXISTING BLDG. A"� � I certify that in the performance of the work for which this (((/// e permit is issued, I shall not employ any person in any manner OWNER ,Y bre.C�1 so as to become subject to the Workers' Compensation Laws. ~ OCCUPANCY GROUP MAIL 1 2�1 a AD DR E 5 S�pZ �_ J� U Date Applicant • -- La NOTICE TO APPLICANT: If,after making this Certificate ofciTY TEL r 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 USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. 0 deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 0 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. D 7 PARKING License Number Lic. Class REq'D PROVIDED J �ttXhA�fli � SPACES LIMITED TIME USE Contractor DateN r ot DATE _77DATE FROM: TO: ��9 �-L•T 0 I am exempt from the licensing requirements as I am a licensed architect or a registered rofessional engineer SIZE OF NO. OF INSPECTOR'S p SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES mess and PIofessions Code). PRESENT USE OF BUILDING FINAL APPROVAL I • ��11''Ir= �� Lic.or Reg.No. Date N =~ F A HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's ( N1 moi/ 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 I hereby affirm that there is a construction lending agency o7k, ividet OrMP, j for the performance of the work for which th' ermit is issued(Sec.3097,Civ.Q.�Zf3��G7 7� �V( Lender's Name J �7�0 44JI'aV p,}^r /}� „,I� PROPOSED MAX. OCC. Lender's Address ! f,/y Y(� r) 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 and State laws relating to building construction, and hereby athorize representatives of this County to enter TOTAL FEE upon the abomentioned I)roperty for inspection purposes. eu c-7 O i SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o Permitt Date t i I WORKERS'COMPENSATION DECLARATION CE 875(11-B4) MISCELLANEOUS APPLICATION ' I hereby+ affirm that I have a certificate of consent to self ' insure, or a certificate of Workers'Compensation Insurance,or ) COUNTY OF LOS AifdELLS BUILDING AND SAFETY DIVISION u a certified copy thereof(Sec.3800,Lab.C.). - I I-0 I Policy No. Company FOR APPLICANT TO FILL IN ADDRESS 70,0 ' ❑ Certified copy is hereby furnished. IS LDING T/- �L LOCALITY S ADORES. MILCE i7 (eM `� GT i ) Certified copy is filed With the county building inspection g LOCALITY t cwoss ST 1001- department. . Date Applicant NEAREST a15TR ICT�NO GRO}1P ITrYOPNESTI ., / P ESSBD BY CROSSST. STRIC 04 �`d•( (/ i CERTIFICATE OF EXEMPTION FROM WORKERS' I DESCRIPTION LOT NO. BLOCK MAP HIGHWAY COMPENSATION INSURANCE I NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLOCS. (This section need not be completed if the work Involved TRACT NOW ON LOT U9E ZONE ISP ECIAL CONDITIONS by the permit is for one hundred dollars (SI00) or less.) uSE OF SIZE OF LOT EXISTING BLDG. �J I certify that in the performance of the Work for which this permit is issued, I shall not employ any person in any manner g OWNER D�ESV S Ri;5 umar11V02 so as to become subject to the Workers' Compensation Laws. B MAIL � � /V, AALikiGr1N �il� OCCUPANCY GROUP _ ( Date Applicant ADDR E.S T NOTICE TO APPLICANT: If,after making this Certificate of � CITY TML OCCUPANT LOAD -- Exemption, you should become subject to the Workers' EL/VfG^Jj� APRLICATIONFOR �-0�7� EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- } with comply with such provisions or this permit shall be TRAILER USE L-1GEOLOGY 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 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. r INC RBO'O PROVIDED I I H 54FACES License Number Lic. Class LIMITED TIME USE LL w Contractor Date DATE DATE room! TO: n t 0 1 am exempt from the licensing requirements as I am a INSPECTOR'S 9 i licensed architect OI a registered professional engineer SIZE OF NO. OF SIGNATURE Z acting in m)- professional capacity tSection 7051. Bus- EXISTING SLOG. STORIES f iness and Professions Code). FINAL APPROVAL �r� O PRESENT USE OF BUILDING s v Lic.or Ree.No. Date s I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �� ON LOT ANO USE I hereby affirm that 1 am exempt from the Contractor's } License Law for the following reason tSection 7031.. Busi- ness and Professions Code): NO. PARKING n ElI, as owner of the property. Will do the work and the SPACES PROVIDED structure is not intended or offered for sale tSection 22 7044.Business and Professions Code). v A [-'1 M �� PROPOSED USE OF BUILDING STDRAgI. /✓ TOC{:CJ/7LIF CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency I for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). Lender's Name t PROPOSED MAX. OCC. Lender's Address 25.00 1 I certify that I have read this application and state that the I PERMIT FEE 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 TOTAL FEE 25.00 i upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Nv_ 4ignantr _rmit Date