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•�•1 WORKERS'COMPENSATION DECLARATION CE 878(1 1-84) MISCELLANEOUS A P P L I C AT I O N ,
• insure,
o affirm that I have a certificate of consent Insur tc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION i I
insure, or a certificate of Workers'Compensation Insurance,or •
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING G�
ADDRESS
Certified copy is hereby furnished. BUILDING
LOCALITY
ADDRESS t PAIC
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. Temple City CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROJjP TYPE ESSED BY
GROSS ST. Lae. ImAs
GA
LEGAL • CONST.
I CERTIFICATE OF EXEMPTION FROM WORKERS' (/a /y��
r I COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP HIGHWAY
I H E ) STATE MAJOR SECOND LOCAL
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
1 SIZE OF LOT EXISTING BLDG. '
4'•� i I certify that in the performance of the work for which this C,
permit is issued,I shall not employ any person in any manner OWNER
so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP
& c
Date Applicant ADDRESS ��
TEL. ��
NOTICE TO APPLICANT: If,after making this Certificate of CITY !,e NO. OCCUPANT LOAD
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 or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONIX Panic Devices
I I hereby affirm that I 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. PARKING REO'D PROVIDED
License Number Lic. Class SPACES 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 SIG TUR
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS O
ON LOT AND USE O �''�
I hereby affirm that I am exempt from the Contractor's �� / j III —i3fj(<1 2f 8/99
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING 2418 AN
�'F �j
I, as owner of the property, will do the work and the SPACES PROVIDED I'41i1S1A
�
structure is not intended or offered for sale (Section
7044,Business and Professions Code). //t
CONSTRUCTION LENDING AGENCY X 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
issued(Sec.3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCG.
Lender's Address
I certify that I have read this application and state that thPERMIT FEE '25.00
e
above information is correct.1 agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
r and hereby authorize representatives of this County to enter TOTAL FEE 25.00
•,.1 I upon the above-menti leiproperty for inspection purposes.
• S ZI -57SEE REVERSE FOR EXPLANATORY LANGUAGE
' j Signature o Permittee Date