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WORKERS COMPENSATION DECLARATION 75(11 84)
CE 875 MISCELLANEOUS APPLICATION
CE 8
I hereby affirm 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) el A
Policy No Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished BUILDING / rCS74�lJ�C�
DRESS LG cc..77 LOCALITY
XM
Certified copy is filed with the county building inspection LOCALITYI n',
�7. NEAREST
department " �/ `"� CROSS ST
Date Applicant SS
/ �C �f ) DISTRICT NO GRO�1P TYPE PR CESSED BY
CROSS ST �•^/,�J L/ p� /,J / CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL l vo 1/
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY
rvO (CIRCLE) STATE MAJOR S OND LOCAL
NO OF BLDGS
(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
I certify that in the performance of the work for which this sl E of LOT EXISTING BLDG o
permit is issued I shall not employ any person in any manner OWNER 01 yL} s�
so as to become subject to the Workers Compensation Laws IL /, OCCUPANCY GROUP o
Date Applicant
f�AD RESSLt�O /�/ Fiet9-�� C~.7NOTICE TO APPLICANT If after makinthis CertificateofY No OCCUPANT OCCUPANT LOAD
Exemption you should become subject g to the Workers z
Compensation provisions of the Labor Code you must forth APPLICA ION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION No Spec Know[
deemed revoked Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter - SAFETY PERM (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 REQ D D PROVIDED D
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 ND OF INSPECTOR S
acting in my professional capacity (Section 7051 Bus E ISTING BLDG STORIES S NATURE
mess and Professions Code) /y /]
Lic or Reg No Date PRESENT USE OF BUILDING Uj17rn� f / FINAL APPROVAL ,� 7_
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS `tel # • 0 • 0 88
ON LOT AND USE
I hereby affirm that I am exempt from the Contractors f ) 0 0 0 e 0 0 GO
License Law for the following reason (Section 7031 5 Busi
nessand Professions Code) NO PARKING p
El 0509 88
I as owner of the property will do the work and the SPACES PROVIDED E/
structure is not intended or offered for sale (Section
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY 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 OCC
Lender s Address
O
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
d hereby authorize representatives of this County to enter TOTAL, FEE a
Don tov mentioned property foo on purpos
SEE VERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date