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WORKERS COMPENSATION DECLARATION
CE 875 M I SC E L LA NX O U S APPLICATION
CE 875 (2 80)
I hereby ifflrm that I have a certificate of consent to self 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)
Policy BUILDING
Company FOR APPLICANT TO FILL IN ADDRESS
❑ 'certified copy Is hereby furnished BUILDING ) 7� LOCALITY
F-1Certified
2 Al / _
Certified copy is filed with the county building Inspection NEAREST
department LOCALITY -/ CROSS ST
Date Applicant NEAREST �I DISTRICT NO OUP TYPE D B
CROSS ST p y� CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL �/
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY
N (CIRCLE) STATE MAJOR SECOND LO NO OFL
(This section need not be completed If the work Involved TRACT NOW ONBLOT S USE ZONE PECIAL CONDITIONS O
by the permit is for one hundred dollars ($100) or less) U
✓ i USE OF
SIZE OF LOT ^ / EXISTING BLDG // cc
certify that in the performance of the work for which this 0
permit is Issued I shall not employ any person in any manner OWNER
so as to become subject to the Workers Compensation Laws MAIL r OCCUPANCY GROUP (~j
AD DRESS /LP A^/ a
Date Applicant to
NOTICE TO APPLICANT If after making this Certificate of CITY �/ NOL��G OCCUPANT LOAD Z_
Exemption you should become subject to 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 TRAILER USE O GEOLOGY INSPECTION
deemed revoked ❑ NO Spec Knowl ❑
Panic Devices ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Rf
I hereby affirm that I am 1iLensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS ❑
9 (commencing with Section 7000) of Division 3 of the Busi
ness and Professions Code and my license Is in full force and PARKING
effect SPACES REQ D O PROVIDED D
License Number Lic Class
LIMITED TIME USE
Contractor Date DATE DATE
rROM 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 7051 Bus EXISTING BLDG STORIES ��� Gf9m^"^tsI SaJ
IneSS and PrOfeSS10I1S Code) PRESENT USE OF BUILDING /� /) FINAL APPR V A L
G e w CJ
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION No O EXISTING BUILDINGS
ON LOT AND USE
I
I hereby affirm that I am exempt from the Contractors
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) No PARKING 3 11 9 LG A
ElSPACES PROVIDED
I as owner of the property will do the work and the
structure is not Intended or offered for sale (Section # o 0 0 0 3 0 I
7044 Business and Professions Code) PROPOSED USE OF BUILDING 2 0,0 6 2 5 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a LonstruLtion lending agency o o; b 2 5 0 o cJ
for the performance of the work for which this permit is t
issued(Sec 3097 Civ C) 0 CO 2-8 2
Lender s Name PROPOSED MAX OCC
Lender s Address PERMIT FEE
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 r
ordinances and State laws ielatmg to building construction TOTAL FEE
and hereby authonTe representatives of this County to enter
upon a above mentioned property for inspection p rpos e SEE REVERSE I-OR EXPLANATORY LANGUAGE
Signature of Permittee 9ate