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WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS A PLICATIOW ,P
I lterdby 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 thereof(Sec. 3800,Lab.C.).
Policy No� Company FOR APPLICANT TO FILL IN BUILDING
/� n ADDRESS
Certified copy is hereby furnished. BUILDING Awn iVC51'� 1 Lv P LOCALITY
SS
ADORE
Certified copy is filed with the county building inspection LOCALITY NEAREST 67
department. CROSS ST.
Date Applicant NEAREST ) DISTRICT NO. GROUP TYPE P CESSED BY
_ CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o y
COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP HIGHWAY
NO. OF BLDGS.
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
!!��(�(�
(This section need not be completed if the work involved TRACT, acto.02r NOW ON LOT a, USE ZONE SPECIAL CONDITIONS
by the permit, is for one hundred dollars ($100) or less.) �` ((''�� USE OF
SIZE OF LOT ��'�® p7.CI.. EXISTING BLDG.
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
so as to become subject to the Workers' Compensation Laws. MAIL _�7_ MM OCCUPANCY GROUP 3
ADDRESS S�.33 A�!v � s
Date Applicant �+ I„
NOTICE TO APPLICANT: If, after making this Certificate of clrY �1l`0 1� L No`� OCCUPANT LOAD a
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
I hereby affirm that 1 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 l h`j Afcf1 tay% 0 IL(SZ PARKING
SPACES REQ'D D PROVIDED D
License Number Lic. Class PA7-10
LIMITED TIME USE
Contractor Date DATE DATE
0 I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF { 'gyp/ NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. \ ZR(1. STORIES SIGNATURE
inessand Professions Code). PRi ��G. FINAL APPROVAL ESENT USE OF BUILDING `7 / 9
Lic.or Reg.No. Date - /
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1'''
ON LOT AND USE ( AT-F
I hereby affirm that I am exempt from the Contractor's ^ ^ Ht_.,.•i °•a
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
� SPACES PROVIDED '•�" '`�
I-1 -' as owner of the property, will do the work and the ;• .i.' i is
structure is not intended or offered for sale (Section " 'f' "� +� '
7044,Business and Professions Code). 'l N
-
PROPOSED USE OF BUILDING `%'•r-Vii-•'"'�~'� 11 - 75
! S:1_::1•, S_}+-a t'.,:
CONSTRUCTION LENDING AGENCY I I f'-;1 c
I hereby affirm that there is a construction lending agencya_i
for the performance of the work for which this permit is I ,
issued(Sec. 3097,Civ:C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address 6�O
PERMIT FEE n' "
I certify that I have read this application and state that the .44,I °�I':"''''''
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and St to laws relating to building construction,
Sh aut a representatives of this County to enter TOTAL FEEEe a ioned property for inspection purposes.
t SEE REVERSE FOR EXPLANATORY LANGUAGE
n re Permittee Date