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WORKERS'COMYLNSATION DECLARATION 76M444
CE 875 (11-84)
M ISCELLA_NEOUS APPLICATION
1 hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES �' 4 BUILDING AND SAFETY DIVISION
insure, or•a certificate of Workers'Compensation Insurance,or
a certified copy-thereof(Sec.=38110,,Lab.C.).
Policy No.._.--_CompanyFOR APPLICANT TO FILL IN BUILDING /r3yy�
ADDRESS 77 7 7
Certified,copy is hereby furnished. BUILDINe4( yI
XX ADDRESS 2*1 y LO CA LIT
,
❑ Certified copy Is filed with the county budding inspectiovn- LOCALITY .NEAREST -
department. Ay. - CROSS ST':'
Date _Applicant_ NEAREST �� L/ DISTRICT NO, GROUP TYPE. CESSED'BY
- CROSS ST. [j•� CON
CP•RTI ICATF,OF,EXEMPTIONFROM-.WORKERS'
COMPENSATION INSURANCEDESCRIPTION LOT NO. BLOCK MAP ..6—AY
- - No. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF SLOGS. -
(Lhls section need not be completed if the Wolk Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
SIZE OF LOT EXISTING BLDG. }
1 certify that.in the performance of the work for which this ci
permit is issued, I shall not employ any person in'any manneXX OWNER of building UFe€R-TZ ='
so as to become_subject to the Workers' Contpensiltion Laws. MAIL2 ��p.�. �-�,[l OCCUPANCY GROUP ��
'ADDRESS,,33 f5buµ-•c-VL/ •` �+ -. li�]
Daae ---- Applicant —
OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
COntpensation provisions of the Labor Code, you must forth- _ ❑
with etllllply with such pro\'Isigns'or this permit sball'-lie TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
OCCUPANCY INSPECTION E] Panic-DevicesE -
1 IC:LNSED CON
TRACTORS'DECLARATION
I hereby affl rill that I am licensed tinder provisions of Chapter SAFETY PERMIT EJ 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 alx
effect. Name of business PARKING REO'D PROVIDED I
SPACES E:= _J
I
License Number - Lic. Class oe
LIMITED TIME USE
Contractor---- --- Date DATE DATE
_ EJI aexempt from the licensing requirements as I am a _
lm INSPECTOR"S
icensed architect or a registered professional engineer sae of NO..OF s NATURE
acting in any professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code).
SINAL APPROVAL '
PRESENT USE OF BUILDING /
Lie.or Reg. No. _ Date, 1- -q
-
HONIF OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS a
` ON LOT'AND USE
.hereby affirin that-I am exempt from the Contractor's / 1 (_(•3i.,f(E—t„f:_?3 t i.
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING t••}�A " ”'
SPA'CES.PROVIDED
1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section,
7044,13usiness and,ProfessionsC'ode).
CONS'] LENDING AGENCY PROPOSED USE OF BUILDING
'
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.J.
Lender's Name
- PROPOSED MAA.*OCC.. _
Lender's Address—---_--_ —--
PERMI.T FEE25 . 00
'
I certify that I have read this application and state that the
• above information is correct. I agree to'comply tvitll all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby-authorize representatives of this County to enter TOTAL FEE 25,_QQ
upon the above-mentioned property for inspection purposes.
XX: SEE REVERSE FOR EXPLANATORY LANGUAGE
XX
Ci tu;lturc i l I'CrIll ilI0C Dntc