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'RS'COMPENSATION DECLARATION 76M444
CE 875 (2-80) MISCELLANEOUS APPLICATION
nsu r borre sf clemifi ate of Workers'hat I have a certificate
Compensation Insurannsent ces or
COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified.copy thereof(Sec. 3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING A—
ADDRESS L� 5109
Certified copy is hereby furnished.O BUILDING / (��ADDRESS `� SSA Jl.iit /Ci - LOCALITY /) `
Certified copy is filed with the county building inspection NEAREST /) �J�Cr
department. LOCALITY CROSS ST. L J V AL D4
Date Applicant FNEAREST � DISTRICT N . G OUP TYPE PRO C S D BY
CROSS ST. L pS (y�IGfid �•
s v CONST.,/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY }
rvo. (CIRCLE) STATE MAJOR SECOND OCAL d
(This section need not be completed if the work involved NO. OF BLDGS.
P TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0
by the permit is for one hundred dollars ($100) or less.)
USE OF
SIZE OF LOT EXISTING BLDG. ( tr
I certify that in the performance of the work for which this�) V" 0
x
permit is issued, I shall not employ any person in any manner OWNERI—
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP U
MAIL IjI
ADDRESS
� R(1 d
Date Applicant to
;rI �� TEL. %/� �_ ��/
NOTICE TO APPLICANT: If, after making this Certificate of CITY G TE %— 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. ❑ Pani PDevices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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-
ness and Professions Code, and my license is in full force and
effect. PARKINGr��I
SPACES REO'D 1..� PROVIDED
License Number Lic.Class
LIMITED TIME USE
Contractor Date
DATE I DATE
F1
FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code).
PRESENT USE OF BUILDING n FINAL APPROVAL
Li c.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION ON 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
❑ SPACES PROVIDED
1, as owner of the property, will do the work and the # • • • e 8 8
structure is not intended or offered for sale (Section • • • • e • •
7044, Business and Professions Code). PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY _ �SCJj;(//61- 46it�C� 0 5 1 .0-8'5
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
PERMIT FEE
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, TOTAL FEE l
and hereby authorize representatives of this County to enter \ (7
upon the above-mentione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date