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RKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875 f�
reby a cirmert that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ,lull
sure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN ABUILDING
DDRESS 5
Certified copy is hereby furnished. BUILDING c //p
ADDRESS J !!CI LOCALITY
Certified copy is filed with the county building inspection LOCALITY
/�9� NEAREST
department. -v / 0L/ CROSS ST.
Date Applicant NEAREST Q�/J DISTRICT NO. GROUP TYPE P ESSED BY
CROSS ST. //4� CONST
LEGAL
CERTIFICATE OF EXEMPTION FROM WORKERS' O� —I_ u
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP �/ HIGHWAY
rvo �j
NO. F BLDS. ,7 (CIRCLE) STATE MAJOR SECOND LOCAL
G
(This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF /^
SIZE OF LOT EXISTING BLDG. / —L_-1
I certify that in the performance of the work for which this ill
permit is issued, I shall not employ any person in any manner OWNER /f (,( y)
so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP �
MAIL A
ADDRESS 6b O ddly
Date Applicant CJ,
NOTICE TO APPLICANT: If, after making this Certificate of CITY NOL /�O OCCUPANT LOAD N
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT
9 (commencing with Section 7000) of Division 3 of the Busi- E] (LIST ITEMS BELOW) NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. PARKING REgD PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
El FROM:
I am exempt from the licensing requirements as I am a TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
IGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT SE OF BUILDING
Lic.or Reg.No. Date
4-ow llge"er
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
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-
ness and Professions Code): NO. PARKING
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USA OF BUILDING
I hereby affirm that there is a construction lending agency A1041WA,
for the performance of the work for which this permit is I l�Jyr
issued(Sec. 3097,Civ.C.).
Lender's Name I
PROPOSED MAX. OCC.
Lender's Address n
I certify that I have read this application and state that the PERMIT FEE
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL, FEE
UT o the a
bm tioned property for i pection pur ses/
SEE REVERSE FOR EXPLANATORY LANGUAGE
a
ure of Permittee Date