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WORKERS'COMPENSATION DECLARATION '
CE 875(2-80) MISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I have certificate of consent to self i COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,or a certificate of Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ F /yCertified copy is hereby furnished. RESS ���d—1 LOCALITY r
❑ Certified copy is filed with the county building inspection NEAREST
department. Loc LITY "Q �{ cRoss ST.
Date Applicant EAREST � DISTRICT NO. �RUPTYPE PROC SSED BY
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO.
No. (CIRCLE) STATE MAJOR SECOND LOCAL O
OF BLDGS.
(This Section need not be completed if the work Involved TRACT NOW ON LOT USE'ZQNE rIAL CONDITIONS V
by the permit is for one hundred dollars (SI00) or less.) USE OF
SIZE OF LOT 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 mannerNER VL dl.�rt (� ® U
AIL
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP ^ IL
ADDRESS 01 Q V�� IL
Date Applicant N
TE q
NOTICE TO APPLICANT: If, after making this Certificate of elTv Q 4 Yklk NOL �.3 OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR I EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION
❑ C] No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic D@VICES 1:1
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) I NO. OF EXITS a
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
,effect.,e PARKING
. SPACES REQ'D PROVIDED
License Number Lic.Class LIMITED TIME USE
;Contractor Date DATE D AT E
❑ 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 7OS1, BUS- EXISTING BLDG. ( STORIES SIGNAT
iness and Professions Code). PRESENT USE OF BUILDINGFINAL APPROVAL -
Lic.or Reg.No. Date W '
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS i
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- 7.2 9.7 A
ness and Professions Code): No. PARKING
SPACES PROVIDED ,
❑ I, as owner of the property, will do the work and the Y 0 0 0 0 8,8
structure is not intended or offered for sale (Section
7044,Business and Professions Code). c o 0 0 0 o D
ROP OSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY ► 202-83
I hereby affirm that there is a construction lending agency I N B
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
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
and hereby authorize representatives of this County to enter
u the above- entioned property for inspe5idn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
naro
f e i ee Date