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WORKERS'COMPENSATION DECLARA I roN
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
mw.re, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof Sec. 3800,Lab.C.). m
Policy Noompany���/r2ta��55(/[i FOR APPLICANT TO FILL IN BUILDING
d �n,� ADDRESS Cr +(L
Certified copy is hereby furnished. BUILDING S�2 j �� /� C,
ADDRESS / LOCALITY G'
Certified copy is filed with the countyb ing inspection LOCALITY NEAR EST
department. CROSS ST.
Date 9� Applicant NEAREST DISTRICT �p GR UP___TTYPE P CESSED BY
CROSS ST. j�D // ,) CONST. / J
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J o ' exC-
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.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER ,p E LI—h-N
so as to become subject to the Workers' Compensation Laws. I OCCUPANCY GROUP a
Date Applicant J /// EL•` .7 ,� L,J
NOTICE TO APPLICANT: If, after making this Certificate of CITY ���( (� vo.t ,_c�fi -jL OCCUPANT LOAD
Exemption, you should become subject to the Workers' fti 'i9L__.
Compensation provisions of the Labor Code, you must forth- APPLICATION F 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
9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT ❑ (LIST ITEMS BELOW)
NO. OF EXITS
ness and Professions Code, and my license is in full force and l7llt� � �x�
effect. REq•D PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INS TORS
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIW ATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF (STING BUILDINGS C —1 L
ON LO AND USE /1��
I hereby affirm that I am exempt from the Contractor's 17
License Law for the following reason (Section 7031.5, Busi- €_i I�l'—.3
ness and Professions Code): No. PARKING
r r '.
F-1I, 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.C.).
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,
and hereby authorize repres es of this County to enter TOTAL FEE
upon the above-mentionedropert for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
--
ignature of Permittee Date
WORKERS CUMPENbAIIUN llr(LAKAIIUN 200063DPIW 2/90 MISC:E.LLANEOU5 APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
rmsure or a certificate of Wdrkers Compensation Insurance or
i a certified copy thereof (Sec 3800 Lab C)
I
Policy No Company FOR APPLICANT TO FILL IN BUILDING
BUILDING ADDRESS ADDRESS
Certified copy is hereby furnished g 53 ,Z q 6,08wir AA e
LOCALITY
Certified copy is filed with the county building Inspection CITY ZIP
department r2--ilft C � C1 R -0 NEAREST
CROSS ST
Date Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY G
CERTIFICATE OF EXEMPTION FROM WORKERS CONST
i LOT NO MAP HIGHWAY (�„
COMPENSATION INSURANCE TRACT BLOCK
No (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if the work Involved ASSESSOR MAP BOOK PAGE PARCEL USE ZONESPECIAL CONDITIONS cc
by the permit is for one hundred dollars ($100) or less) I I C
TEL NO
i eify er
I certify that in the performance of the work for which this P,�M� hv�a 8}8-53S-S�8 LL
permit is issued I shall not employ an} person in any manner ADDRESS _
I so as to become subject to the Workers Compensation Laws OCCUPANCY GROUP tr
z
Date Applicant CITY ZIP
NOTICE TO APPLICANT If after making this Certificate woad
of Exemption you should become subject to the Workers APPLICATION FOR OCCUPANT LOAD
Compensation provisions of the Labor Code you must forthwith EXIT HARDWARE
comply with such provisions or this permit shall be deemed TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knowl ❑
� revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION[it Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter IfflSAFETY PERMIT❑ (LIST ITEMS BELOW) a
I 9(commencing with Section 7000)of Division 3 of the Business ame O 118 eS3 NO OF EXITS
and Professions Code and my license is in full force and effect o
PARKING REO DD PROVIDED D
License Number Lie Class 6(i y It— '-i oL l SPACES
i Contractor Date LIMITED TIME USE
❑ I
DATE DATE
FROM am exempt from the licensing requirements as I am a TO
licensed architect or a registered professional engineer
acting in my professional capacity(Section 7051 Business SIZE OF BLDG STORIES INSPECTOR
TORE
and Professions Code)
Lic or Reg No Date PRESENT USE OF BUILDING FINAL APPROVAL
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 70315 Business 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 1 PROPOSED USE OF BUILDING
Business and Professions Code)
CONSTRUCTION LENDING AGENCY
i I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
i (See 3097 Civ C) PROPOSED MAX OCC
Lender s Name APPLICANT(PRINT) TEL NO
Jai Sa }'� SIS-$2f-till
Lender s Address ADDRESS
I certify that I have read this application and state that the S3 LA Sal d-Wot mile
above information is correct I agree to comply with all County
� PERMIT FEE
I ordinances and State laws relating to building construction and
hereby authorize representatives of this County to enter upon ISSUANCE FEE
t ,I the above mentioned property for inspection purposes
I TOTAL FEE _
g SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
I
11 �r\'(��:{LRS�COh1PL•NSATION DECLARATION 76Maaa
I _ MISCELLANEOUS APPLICATION
hereby affirm that t have a certificate of consent rself CE 675 (11.84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
� htsure, or a certificate of Workers'Compensation Insurance,
e,or _
a certified copy thereof(Sec. 3800. Lab.C.).
Policy No. CompBUILDINGany FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished. BUILDING LocAL1TY
iADDRESS
i Certified copy is tiled with the county building inspection LOCALITY NEAREST
i
department. cR use ST.
bate_ ___ \ niirtnt ` NEAREST 0ISTR ICT NO. I GROU TYPE y/' pR ESSED BY
p. CROSS ST. ��� ; CONST.%/ !
(TR 1 IFICATL OF EXEMPTION FROM WORKER" LEGAL 71
COMPENSATION' INSURANCE DESCRIPTION LOT NO. j.LOCK � nwP „IG ww wr
NO, ICIRCLC? STATE MAJOR SE OO NO LOCAL
- 'T NO. OF HUGS.
( 1)115 section neet! not Ili' completed If rile :Fork Involved TRACT (NOW ON LOT USE �ONE!SPE CIAL CONDITIONS
v the permit is for me hundred dollars (5100) of less.) IUSE OF
SIZE OF LCT !EXISTING BLDG.
'2rzifv that in he ^erfonnance oL :he work for `.vhv:h -.itis
rcrmit is issued, I shall nut ernriov iv ae.son in any man ne OWNER L � /'/
Cy bu3__C_il� ``
u= :a ;n ?,c:'nn,e �.uhie;: ;n !hc ',:'�,rkers' Cantpensation Law.. MAIL # CCCUPANC`' GRCUP 0 i
ADDRESS 4q
/ TEL' CCC; ;N
.P T LO AD I
NOTICH f( APPLICANT:
_ICANT: If, after makine this Certiut,:ate of CITY � No.
fi>:emption,
you should becnme subiect to the Workers
(',)Inrensation Prov!siOns of :Ire Labor Code• you must forth- / -KATION =0F EXIT HARCVVAR
lilt Complc with stl:ll pro%isions or this permit shall be
TRAILER USE 7 GEOLOGY INSPECTION J No Spec. Know 1.
OCCUPANCY INSPECTION f^ Panic Devices I '
I I(TNISFI)1, ON I RACMRS DEC LA RATION
cnbl finn :iia; I ant licensed uncle:provisions of Chapter r,
U SAFETY PERMIT y! {LIST ITEMS BELOWi
�r.lmmenc;rts with Seaton X000) of Division � of the Bust
NO. OF =XITS
Hess and Prof"'won, C ole, and m% license is in !oil force a
Nafne c bus_ness PARKING SPACES REO'7 i PRO•JIpED
�� I LLL���JJJ
\Illnhe L1Mi ED TIME USE
t,ntr:,c�<`r I`atc_ �wTE �a rE
lI I Rorn: =o: i
ant escrnpr !rum :he licensing requirements as i am a
liccnseti architec: or a registered professionainn et)_eineer SIZE OF i No, of INSPECTOR S
actino In illi- rrotesSlUnai c2rocit': (Section 705 . Bus- EXISTING BLDG. STORIES SIG IATE
nessandl'rufessiuns(ode?. Ft L ROYAL
-11L.I)r Re•=. NO _ —_ Date PRESENT USE OF BUILDING
011
HOMI: OWNi R-iU ILDER DECI.ARATION p7o. OF EXISTING BUILDINGS
ON LCT AND USE
I herehv affirm that I am exempt from the Contractors
i License I.aw for the iutle"mR reason (Section -031..,. Busi-
ness :mei Prntessions' odc!: NO. PARKING
t, as owner of the aruoer}•. will do the work .and the SPACES PROVIDED
structure is not intended or offered for sale (`rection
1044,Business and Professions Code).
PROPOSED USE OF BUILDING -
CONS IRi.("IION LENDING AGENCY
I hereb> affirm that there is a construction lending agency
fur the performance of the work for which this permit is
issued(Sec. 3097, Civ- .1. :....�•.: .-.....-:.
Lender's Narne
PROPOSED MAX. OCC.
Lender's Address _--- --- _ - .-- --
25 . 00
I certify that I have mad this application and state that the PERMIT FEE
i ahuve information is correct. 1 agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
i and hereby authorize representatives of this County to enter TOTAL FEE
25 - 00
upnn ill ahu�ve-mention property for inspection purposes.
SEE REVERSE FOR EXPLANA'T'ORY LANGUAGE
A,i ture: y �//