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Home My Public Portal About4700 H MILLER DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION CE 875 I thereby�''.Iffirin�that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,.!r a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING...... Certified copy is hereby furnished. wooRess�7pp/yyitLLSR .a?, H T£H CIT CA 9/J� LOCALITY y iCertified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NOFGRPUP TYPE CESSED BY CROSS ST. �� !f _ •) CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLOGS. (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. k--, Ci permit is issued, I shall not employ any person in any manner OWNER �4 F k�d.I�;.Q1V-rA1 W09. E41r-A +2 5 so as to become subject to the Workers' Compensation '�Laws. MAIL >:L MoNr� OCCUPANCY GROUP a ADDRESSCA!h Date Applicant LULI NOTICE TO APPLICANT: If, after making this Certificate of4 CITY FL t1V1VT& ITvo�s.18 �p•�3-o078' 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 USEGEOLOGY INSPECTION Eldeemed revoked. E] ElNo Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices El 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 m license is in full force and n rte- h effect. rvry %II-' 1 aJ �^VC`•� PARKING REQ'D PROVIDED �� License Number Lic. Class '57 — N / C SPACES LIMITED TIME USE Contractor Date DATE OATS EJI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO.OF INSPE oR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sic URE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT ANI 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 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 J PROPOSED MAX. OCC. Lender's Address PERMIT FEE /) � Lam/ I certify that I have read this application and state that the ` '' above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws gokting to building construction, and hereby authorize rep nt i s of this County to enter TOTAL FEE �- •:� upon the above-me i inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signa a of rmittee 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 Certified copy is hereby furnished. BUILDING I / LOCALITY ADDRESS (� / Certified copy is filed with the county building inspectionOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST CROSS ST. LO 2� ,7 L DISTRIC N�}. GROUP TYPE PROCESSED BY �'+`Q'� �• � CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 6 �/ COMPENSATION INSURANCE DESCRIPTION LOT NO. -LOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL No. (CIRCLE) NO. OF HLDGS. (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.) E OF SIZE OF LOT EXISTING BLDG.us 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 cLc� ou-eve• y so as to become subject to the Workers' Compensation Laws. MAIL /� OCCUPANCY GROUP ' ADDRE S 4a65 /„• $C��d�I�'�- Avg CD Date Applicant p ,Q ,,, -PAnA ts TEL. (p( )) 42�OU�U OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY o v4e No. l0 `t V N 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 or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El 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 9 NO. OF EXITS ness and Professions Code,and my license is in full force and effect. LC ARKING REq'D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO-- 0 F FROM: To. INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG, STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL ZS;9 PRESENT USE OF BUILDING Y, t, Lic.or Reg.No. Date z I.. _ ,,- 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 ElI, 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 X 1 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 above information is correc I agree to comply with all County ISSUANCE FEE ordinances and State law relating to building construction, and hereby author' re esentatives of this County to enter TOTAL FEE upon the abo o d property for inspection purposes. 2 I a SEE REVERSE FOR EXPLANATORY LANGUAGE LL Signature o ermittee J� Date