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CE 875(11-84)
WORKERS�COMPENSATION DECLARATION MISCELLANEOUS APPLICATION
CE 875
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 'fl
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING J_ )
ADDRESS (J /
` IP
Certified copy is hereby furnished. BUILDING
7 o a v 1)E �T. LOCALITY ,�
Certified copy is filed with the county building inspection LOCALITYNEAREST /
department. LG L'IT cRoss Sr.
Date Applicant NEAREST �^ ' `y DISTRICT NO. GROUP TYP PROCESSED BY
CROSS ST. CO ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL f
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIG RW AV
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This seetlon 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 _
SIZE OF LOT !�(J �Q EXISTING BLDG.
I ceitify that in the performance of the work for which this VCD
permit is issued, I shall not employ ny person in any manner OWNER &43- �f�0 r-i s�
so as to become subject to the W er ' Comp sation L s. MAIL ,{ OCCUPANCY GROUP o
ADDRESS ,S' � S �•
Date Applica TEL. W
NOTI TO APPLICANT: ter aking this ertificate of clrY No. x'75 _;IqO 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. _
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION EJPanic Devices
ED
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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. td PARKING REQ'D PROVIDED
/ � / SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE R DATE •',
FROM: TO:P�•r•T JL
0 I am exempt from the licensing requirements as I am a _
licensed architect or a registered professional engineer SIZE OF pX NO. OF — INSPECTOR•,S �_;
acting in my, professional capacity (Section 7051, Bus- EXISTING BLDG. 1 V 8 STORIES ' •=�7f SIG 'Arugg,5'
iness and Professions Code).
PRESENT USE OF BUILDING &.5�pE �V FINAL APPROVAL �
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE ®(� CHECK -'
I hereby affirm that I am exempt from the Contractor's _;}•jANK �I l
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 - l�{j�l�—I]�,jl'_s 1 . 1/�.�'''j
u.
structure is not intended or offered for sale (Section
7044,Business and Professions Code). l•.; i
-i I
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.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE �
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE J��
ordinances and State laws relating to building construction, Lo
and he y authorize representatives of this County to enter TOTAL FEE Kja
�(
upo e above-menti ed proper for inspection purposes.
g SEE REVERSE FOR EXPLANATORY LANGUAGE
nature o e'rmittee Date