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NWOVKERS'COMPENSATION DECLARATION 76M444
1' CE87b (2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have e certificate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insl!re, or a cg^tificate of Workers'Compensation Insurance,or
a cCrKAed copy thereof(Sec. 3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN ABUILDING
DDRESS 7
❑ Certified copy is hereby furnished: BUILDING /y
'�'f-�— n LOCALITY
❑ AS
DDRES
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY CROSS ST.
Date _ Applicant NEAREST DISTRICT O. G1�OUP, TYPE PROC SED BY
CROSS ST. r (j CONST. -
CERTIFICATE OF'EXEMPTION FROM WORKERS' LEGAL GA
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP H1GNW 4Y STATE MAJOR SEC ND LOCAL d
NO. OF BLDGS.
NO. (C IRCLEJ E 'SPECIAL Q
(This section need not be completed if the work involved TRACT NOW ON LOT USZONE CONDITIONS U
by the permit is for one hundred dollars ($100) or less.) USE of
i X' -
Icertify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. O
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. OWNER Ga� ✓� OCCUPANCY GROUPE� W
MAIL
ADDRESS D Q,yI /�1 � cn
Date Applicant 'l
NOTICE TO APPLICANT: If, after-making this-Certificate of CITY j` NOt _ OCCUPANT LOAD.-
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 GEOLOGY INSPECTION
deemed revoked. ❑ No Spec. Knowl. ❑
OCCUPANCY.,INSPECTION Panic Devices ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed 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 D PROVIDED D
License Number Lic.Class
LIMITED TIME USE
Contractor Date DATE DATE
❑ 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 7051, Bus- EXISTING BLDG. STORIES_ 5 NATURE
iness and Professions Code). PRESENT USE OF BUILDING /�--+� FINAL APPROVAL
Lic.or Reg.No. Date
• • • •
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS • s •I • e o • Z
ON LOT.AND USE _ O a I O�H 5
I hereby affirm that, I am exempt from the. Contractor's '
License Law for the following reason (Section,7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
704'4, Business and Professions Code). OPROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY r+ f
I hereby affirm that there is a construction lending agency Z 0 U9 46 ck,
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name - PROPOSED MAX. OCC. if
Lender's Address PERMIT FEE
I certify that I have read this application and state that the f
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, TOTAL FEE v
and hereby authorize representatives of this County to enter
upon the ab ve-mentioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of rmittee Date