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WORKERS'COMPENSATION DECLARATION 875(2-SO)a
11 1
CE M ISCE LLANEOUS APPLICATION
CE 87
I Hereby affirm that i have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'
rs'Compensation Insurance,or I ,
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company I BUILDING
FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is hereby furnished. UILDING �s J
ADDRESS ji� lT J/ 1AA1,0 LOCALITY
❑ Certified copy is filed with the county building inspection Lo I a //" NEAREST
department. LOCALITY / r CROSS ST.
Date Applicant ONEARESTDISTRICT NO;;1 'OUP TYPE' PRO. SSED BY
CROSS ST. `�� v/I'•� ✓ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK }
NOP �Q" (CIRCLE) STATE MAJOR SECOND LOCAL IL
(This section need not be completed if the work involved NO.- F BLOGS.
TRACT NOWOO ON LOT USE ZONE SP CIAL CONDITIONS U
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG- cc
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 WNER, ei. 4f/� ADD G V
so as to become subject to the Workers' Compensation Laws. AILOCCUPANCY_GROUP 0
ALo 41LU
DDRESS lee� CO
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of .I CITY• TEL �� OCCUPANT LOAD z
Exemption, you should become subject. the' Workers' ( APPLICATION FOR EXIT HARDWARE:
Compensation 'provisions of the Labor.Code,, you must forth- _
with comply With such provisions or this permit Shall be �.I TRAILER USE GEOLOGY INSPECTION
deemed revoked. J+I ❑ ❑ No-Spec'. Knowl. ❑
• LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT L I (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi-
r ss and Professions Code, and my license is in full force and PARKING
effect' SPkCES ' REQ'D PROVIDED
.License Number Lid.Class
LIMITED TIME'USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051,-Bus- EXISTING BLDG: - STORIES SIGNATURE
iness and Professions Code). EFINAL APPROVAL /}
SENT USE OF BUILDING
Lic,or Reg,No. Date 1,0
` c
HOMENO.OF EXISTING BUILDINGS
V
OWNER-BUILDER DECLARATION ON LOT AND USE I `_ Q 7, 4 A
I hereby affirm that- I am exempt from the Contractor's t r o a 0 0
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ( NO.PARKING
SPACES PROVIDED Q o c o 0 0 0 M
❑ I, as owner of the property, will do the work and the I' ' ' '
structure is not intended or offered for sale (Section (i 11091-814
7044,Business and Professions Code).
POSED USE OF BUILDING 5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for wJtich this
p permit is. i
issued(Sec.3097,Civ.C.).
Lender's Name I PROPOSED MAX. OCC. '
Lender's Address PERMIT FEE
- I
I certify that I have read this application and state that my ISSUANCE FEE � I + �
above information a correct.I agree to t comply with all County _ ^
ordinances and State laws relating to building construction, TOTAL FEE .12- 15-1040 /%/GAY{,/
and hereby authorizer resentatives of this County to enter & I
upon the above-me ned property f inspectiop pur oses. SEE REVERSE FOR EXPLANATORY�fAGE
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Signature o er tee Da