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WORKERS'COMPENSATI023DECLAkATION MISCELLANEOUS APPLICATION
CE 876
I hereby affirm that I have CE 875 (11-84)a certificate of t tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure or a corticate of Wor3:eri Compensationn 1nsuImarrance,or
a ce cc. 38
Policy �mpan} �1�� FOR APPLICANT TO FILL-IN ■ADRE■SUDRKNS
Certified copy is hereby furnished. ■UILD IN6 LIT
LO
ADDRESS
ATMQ
iffiled with the county building InspectioII - NEAREST
LOCALITYCRO/■ iT.
pp � 11EAR[/T 1 DWRICT 6 cI TYrE P [f D ■Y
DatelicantCRO/■ IT. `T1I {/1J 3CONSTTE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LT ... BLOCKNO. BLDGS. o• 1'� Bu� STATE YAJOR ■[CON LOCAL
(Tiny cation need not be completed if the work 1IITolved TRACT � NOW ON LOT USE XON[ ■-[CUL CONDITIONS
by the permit is for one hundred dollen ($100) or less.) USK OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this CD
permit is issued, I Shah not employ any person In any n1a>mer orN[R (:�71N 1A
s-.
so as to become subject to the Workers' Compensation Laws. YAIL OCCUPANCY GROUP o
wDDR Esa
Date Applicant L`3
NOTICE TO APPLICANT: If, after making this Certiflcttc of cITY NoL OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shaIl be TRAILER USK ❑ GY INSPECT1oN ❑ No Spec. Knows'.
deemed rovokod_
LICENSED CONTRACTORS DECLARATION occuPANCY IN/PECTIo Panic Devices
I hereby nffIrm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Buss ■wF[TY PER (LIST rrEYf ax-Low)-
NO. OF EXITS
nese and Professions Code, and my license is In full force and ' r '
dffbCt. rARKI E 5 REq'D rROVID ED
/ I ■pwC
License Number's v� Lic Claaa
(+� ♦� LIMITED TIME USE
Contractor Date DAT■ DATA
0 I am exempt from the licensing 1mm to as I am a' ^RDYI TDI
licensed architect or a registered professional engineer ■Iz[of No. oh IN S�Ecro R'■
acting in my professional capacity (Section 7051, Bus- EXISTING ■LDG. JJeqJ2 STORIES ■lanwru
him and Professions Code).
PRESENT U/[ OF BUILDING FINAL APPROVAL
Lie,or Reg.No. Date �1 )
HOME OWNER-BUILDER DECLARATION No.of EXISTING BUILDING■
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's T'*
License Law for the following reason (Section 7031.5, Busi- 3307 93.W
ness and Professions Code): No.BARKING
ElI, as owner of the property, will do the work and the 1eACE/ PROVIDED ITEM
structure is not intended or offered for sale (Section
7044,Business and Professions Code). TOTAL � �
CONSTRUCTION LENDING AGENCY FROROSED US[ OF BUILDING CHECK 93.00
I hereby affirm that there is a construction leading agency ■lIl'� .00
for the performance of the work for which this permit is
issued(Seo. 3097,Civ.C.).
Lender's Name .�}{{ / ?[�C
PROPOSED MAX. OCC. �,RMTVJVl �/ 1.JI7Li "
Lender's Address '
I arr tify tlmt I bave this application and state that the R M I T F[[ ( i
AM 7:55
above information rrect.I agree to comply with all County Ioau ANcs FRU
or
to laws relating to building construction,
and b thoIiZe IW]ves of this County to enter TOTAL.FKK
up ve-m perty for inspection rposez
SEE REVERSE FOR EXPLANATORY LANGUAGE
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