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'ERS'COMPENSATION DECLARATION
CE 875(11-84) M I SC E L LA N k O U S APPLICATION
CE 875
affirm that I have a certificate of consent to c self !! COUNTY OF LOS ANGELES I�. BUILDING AND SAFETY DIVISION
a certificate of Workers'Compensation Insurance,or I ,
I
copy thereof(Sec.3800,Lab.C.). _
:o. Company FOR APPLICANT TO FILL IN BUILDING �J
ADDRESS / _
Certified copy is hereby furnished. BUILDING ll LOCALITY
ADDRESS / �y
Certified copy is filed with the county building inspection
LOCALITY NEAREST
department. CROSS ST.
ate Applicant NEAREST DISTRICT NO. tdlioup TYPE PROCESSED BY
.CROSS ST. I1�Lwr a ff/� 0f
CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I� —�'
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY CIRCLE) STATE MAJOR SECOND LOCAL
NO. (
(This SBCtIOn need not be completed if the work involved TRACT NO. OF BLDGS.NOW ON LOT USE ZONESPECIAL 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. I
permit is issued,I shall not employ any person in aAy manner OWNER 0 ( p�(/ Kt.. ^ ! s�
so as to become subject to the Workers�Compensation Laws. MAIL i OCCUPANCY GROUP o
Date Apphcan ADDRESS yt C
TEL OCCUPANT LOAD
NOTICE TO APPLIC1A�If, after makin his Certificate of CITY Le� No. I y
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLI ATION FOR ;EXIT HARDWARE:
with comply with such provisions oI 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 SAFETY PERMW[]% (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 fn full force and
effect. PARKING R6Q'D D PROVIDED CO
' SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date I DATE DATE
I am exempt from the licensing requirements as I am a FROM: TOI
licensed architect of a registered professional engineer ' SIZE OF' NO. OF INSPECTOR'S
acting m my' professional capacity (Section 7051, BUS' EXISTING BLDG. STORIES
SI ATURE
iness and Professions Code). /^y` FINAL APPROVAL
I� PRESENT USE CF BUILDING
Lic.or Reg.No. Date I
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING UILDINGS 1
ON LOT AND USIV
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
�
I, as owner of the property, will do the work and the ' SPACES PROVIDED FIE
structure is not intended or offered for sale (Section
7044,Business and Professions Code). 1 �J ,._
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 "*jr CY
issued(Sec.3097,Civ.Q.
Lender's NameAM#f;c
r PROPOSED MAX. OCC. '
Lender's Address I , I
t V `^ �1 p I
I certify that I have read this application and state that the PERMIT Fee � l
above information is correct.I agree t coinply with all County ISSUANCE FEE CA
ordinances and State laws relati o building construction, ,
and hereby ize representat' es of this County to enter TOTAL. FEE,
I the - lent' d y..for'nspection pu oses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Per;iitte Nite ',