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WORKERS COMPENSATION DECLARATION
CE 875 (2 801 MISCELLANEOUS A P P L I CATION {�
CE 875 U
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
msc.re or a Lertificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C) f '
Policy No Company FOR APPLICANT TO FILL IN BUILDING QQCC
/J
❑ Certified copy is hereby furnished BUILDING ADDRESS B'
LOCALITY
I� ADDRESS
❑ Certified copy is filed with the county building inspection LOCALITY 7 �f �iS9 NEAREST
department ry CROSS ST
Date Applicant NEAREST C DIST ICTNO GROUP TYPE PROCESSED BY
CROSS ST 9 CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK pp rj HIGHWAY }
I Y _ No r" (CIRCLE) E STATMAJOR SECON L AL
NO OF BLDGS
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars (S100),or less) _ U
I _ y USE OF
SIZE OF LOT (�• Y/�O EXISTING BLDG
I certify that in the performance of the work for which this 0
permit is issued I shall not employ any person in any manner OWNER
so as to become subject to the Workers Compensation Laws F 2 OCCUPANCY GROUP U
MAIL
ADDRESS a
LLI
Date Applicant to
TE
NOTICE TO APPLICANT If after making this Certificate of' CITY 7 NOL OCCUPANT LOAD Z
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 0 GEOLOG NSPECTION C1 No Spec Knowl ❑
deemed revoked `
OCCUPANCY INSPECTION Panic Devices
LICENSED CONTRACTORS DECLARATION ❑
I hereby affirm that I am liLensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) No of EXITS
❑
9 (commencing with Section 7000) of Division 3 of the Busi
ness and Professions Code and my license Is in full force and O >"�A1� PARKING
effect SPACES REO D PROVIDED
License Number Lie Class r
LIMITED TIME USE
Contractor Date DATE DATE
`❑ ( FROM ✓ TO
I am exempt from the hma
censg requirements as I am
licensed architect or a registered professional engineer SIZE OF No -FS 3>�/ INSPECTOR
acting In my professional capacity (Section 7051 Bus EXISTING BLDG �// STORIE
ineSS and Professions Code) PRESENT USE OF BUILDINGz- FINAL APPROVAL 4 /
�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 Contractors
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) NO PARKING
SPACES PROVIDED
❑ i `as owner of the property will do the work and the
structure Is not Intended or offered for sale (Section
7044 Busmess and Professions Code)
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY 316 2 2 A
I hereby affirm that there is a construLtion lending agencv
for the performance of the work for wJlich this permit is i I
issued(See 3097 Civ C) # e • 0 0 3 0
Lender s Name PROPOSED MAX. OCC 2 - 6250
Lender s Address i
PERMIT FEE e e e 6 2 5 O U
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 relating to building construction 0'4, 1 3—8 2
and hereby author17e representatives of this County to enter TOTAL FEE
upon the bove mentironn�ed� property for Inspectpurposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Ignature of Permittee Dae k
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