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WG�s KERS'COMPENSATION DECLARATION 84 54
CE (2-80)
MISCELLANEOUS APPLICATION
1,hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
iIp-re, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab. C.)
Policy No. Company BUILDING ����
FOR APPLICANT TO FILL IN ADDRESS � �- .�b �' VF,
C
❑ Certified copy is hereby furnished. ILOING /) / �) //jJy/ / ADDRESS
❑ ADDRESS (,FSS/,�V// O /Ill b C. ( �' LOCALITY
L� 1 T � r
Certified copy is filed with the county building inspectio NEAREST
department. iocALtrr /eM IE- ` CROss sr.
Date Applicant NEAREST C� .��• ,�� DISTR IC NO. OUP TYPE PROCE D
SS ST. J ( N _� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY >_
NO. (CIRCLE) STATE MAJOR SECON LOCAL d
NO. OF BLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O
by the permit is for one hundred dollars 0100) or less.) USE OF //�j� / U
SIZE OF LOT EXISTING BLDG. f _/V cc
I certify that in the performance of the work for which this �J V
permit is issued, I shall not employ any person in any manner G INNER 77f� �} �T t �� %�( 0
so as to become subject to the Workers' Compensation Laws. MAIL ` Ali
OCCUPANCY GROUP J-� W
DRESS (�/ n/ 16L`'S/44^tE °-
Date Applicant to
Tr
NOTICE TO APPLICANT: If, after making this Certificate of Y 5 �/�/4 No. g� /Z,S1 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 GEOLOGY INSPECTION
deemed revoked. ❑ No Spec. Knowl..❑
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INSPECTION Panic Devices ❑
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. REQ'D PROVIDED
SPACES
License Number Lic.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 INSPE rOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG TURE
iness and Professions Code). A6.1 00
PRESENT USE of BUILDING
FINAL APPROVAL /� ,77
Lic.or Reg.No. Date ((�J
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS # o 0 o s 8$
ON LOT AND USE
0 0 0 0 0 0 0
I hereby affirm that- I am exempt from the Contractor's ZE
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): O.PARKING
ACES PROVIDED 0 8 2 5 8 5
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section J
7044, Business and Professions Code). f._tJJ.OPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY S-P�(f L �� vI U/ E //e fe
I hereby affirm that there is a construction lending agency /7� (! •
for d( performance ofthe work for which this permit is �xGl 0 1 �5 1
issued Sec. 3097,Civ.C.).
Lender's Name s PROPOSED MAX. OCC.
Lender's Address PERMIT FEE
I certify that I have read this application and state that the I\MVVVV
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorize representatives of this County to enter
uponAbove-mentioned property for inspectio purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
f/ Com- e; � y3
Signature of AerAittee Date