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WORKERS'COMPENSATION DECLARAPION i� �200063DPWi2/90 MISCIEI_;LANEOU APPLICATION '
I hereby affirm that I have a certificate of'consent se!f 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.) ;
y' Policy No. Comparry I FOR APPLICANT TO FILL'IN I'01JILDING
BUILPWG ADDRESS •� ,I,ADORESS
❑ Certified copy is hereby furnished. ,� /(li, +
i LOCALITY
❑ Certified copy is filed with the country building insp'Cction CITY 99 ZIP
I department. (,Q /7 ;�cRoss sT.
Date Applicant SIZE OF LOT
NO. BLDGS.NOW ON LOT DISTRICT NO. GROUP TYPE i-ROCE55ED BY
CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' I C
c I COMPENSATION INSURANCE [ TRACT BLOCK LOT NO.
,Jj ;MAP HIGHWAY
t No. (CIRCLE) STATE MAJOR SECOND LOCAL
(This section need not be completed if tltc work in olved ASSESSOR MAP BOOK PAGE PARCEL L`
NO.
ZONE SPECIAL CONDITIONS r
by the permit is for one hundred dollars (;5100) orjless.) - s t
OWNER TEL NO.
r I I certify that in the performance of the work for which this t U
permit is issued. I shall not employ any person in any Milner
J
so as to become subject to the Workers' Compensation(Laws. ADOREss OCCUPANCY GROUP u
I Date Applicant _ CITY ZIP r —
NOTICE TO APPLICANT: If. after makiiig this Cert f Cate I I I OCCUPANT LOAD
of Exemption. you should become subject to the Workers' APPLICATION FOR IEXIT HARDWARE:
Compensation provisions of the Labor Code.you must forshwith
comply with such provisions or this permit shall be deemed TRAILER USE El GEOLOGY INSPECTION❑ No Spec.Knowl. ❑
revoked. 1 1.
OCCUPANCY INSPECTION)91I Panic Devices ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed tinder provisions of C11'apter SAFETY PERMIT❑ $LIST ITEMS BELOW)
'} I 9(commencing with Section 7000)of Division 3 of the Business I NO.OF EXITS
and Professions Code.and my license is in fall force and'�ITect.
+ PARKING• REq'D D PROVIDED D
"s License Number Lir—Class SPACES
y
LIMITED TIME USE
Contractor Date
' +• l '� DATEDATE
_ L ❑ 1 am exempt from the licensing requirements as I 'am a +,FROM: TO:
g licensed architect or a registered professional en;ineer
acting in my professional capacity(Section 7051. Business SIZE OF NO.OF INSPECTOR'S
3 ' and Professios Code). p + I EXISTING BLDG. STORIES SIGN TORE
PRESENT USE OF BUILDING FINAL APPROVAL
Lie. or Reg. No. Date
I I �
HOME OWNER-BUILDER DECLARATION No.OF EXISTING BUILDINGS I
• ON LOT AND USE i
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 703'1.5• Business and
" Professions Code):. NO.'PARKING
SPACES PROVIDED
i ❑ I. as owner of the property, will do the work ana the
structure is not intended or offered for sale(Section 7044. PROPOSED USE OF BUILDING
Business and Professions Code).
1 I
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a.construction lending agency for '
the performance of the work for which this permit is is sued
i I (Seo. 3097.Civ.C.). PROPOSED MAX.OCC.,
Lender's Name APPLICANT(PR T) TEL FJO. L +.
eetou P, any o
Lender's Address -- AD 3R,F,sS
I I I certify that I have read this application and state that the '`i(D 0
above information is correct. I agree to comply with all CMunty PERMIT FEE
ordinances and State laws relating to building.constructiori,and
hereby authorize representatives of this County to enter{upon ISSUANCE FEE
the above-mentioned property for inspection purposes.
I'A I ✓ I TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
a f_; Signature 0f peritiitice '"�Dute