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W°RKERs'c°MPENSATIONDECLARATI°" MISCELLANEOUS APPLICATION
q I CE CE 875 111-84)875
I hereby affirm that I have a certificate of consent to or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a::cVrtifica[e of Workers'Compensation Insurance,,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BU"D'N° 92 OS �. /3R04Z>WAY
ADDRESS
Certified copy is hereby furnished. eu uo ING r /� 4 I, l/r r-.
A O DR ESS ZOS C, B/�D/JDVV�IY ) LOCALITY �c/1//v�� C`T(J
Certified copy is filed with the county budding inspection LOCALITY NEAREST 7
department. ']'EM��� G'Ty CRoss Sr. �NC/N/TA
Date Applicant NEAREST / DISTRICT O. GROUP TYPE P O $SED OY
CROSS ST. cn/G/n/ TL} 5,0 �i _ CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 1l
COMPENSATION INSURANCE Desc RlPnoN LOT No. / BLOCK .D„.A
' „OP (CIRCLe) STATE MAJOR SECOND LOCAL
NO. OF SLOGS. /�
(This section need not be completed if the work involved TRACT / 2 L.//Q NOW ON LOT 2 USE ZONE SPECIAL CONDITIONS:
by the permit is for one hundred dollars ($100) or less.) - USE OF
SIZE OF LOT jRREG EXISTING BLDG.
I certify.that in the performance of the work for which this o_
permit is issued, I shall not employ any person in any manner OWNER MR &MJ75 TAM,ES
so as to become subject to the Workers' Compensation Laws. MAIL (/ OCCUPANCY GROUP
ADDRESS D - .Bo2o/iDW�l J —� CJ
/ate -2 .8 Applicant ,IAAI£5 E. 5NFN 2 _ �D
TEL. LU
NOTICE TO APPLICANT: If, after making this Certificate of CITY 7SA-In[F CIT tf ND. /�`— SAS—/--0069
00 (� OCCUPANT LOAD - D_
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. KnOWI.
LICENSED CONTRACTORS DECLARATION - OCCUPANCY INSPECT16N ❑ . Panic Devices
I herebyaffirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIET ITEM6 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. • +f PARKING
/� ` SPACES REO'O PROVIDED
License Number Lie. Class +' Y/l 6f
Contractor - 'Date �,,j (p ^�p � j DA.LIMITED TIME USE DATE
ElI am exempt from the licensing requirements as 1 am a , n'F9 e
licensed architect or a registered professionalengineerSIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. - 'STORIES / IGNATUR
iness and Professions Code).
PRESENT USE OF BUILDING ,,. FINAL APPROVAL '�
Lie.or Reg.No. Date ”-'
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS '
ON LOT AND USE
ACC
I hereby affirm that I am exempt from the Contractor's -
License Law for the following reason (Section 7031.5, Busi- 330
ness and Professions Code): NO. PARKING �•J��
El1, as owner of the property, will do the work and the SPACES PROVIDED - 1 -ITEMS
structure is not intended or offered for sale (Section . . TOTAL �rO e
7044,Business and Professions Code). 80. !50
CONSTRUCTION LENDING AGENCY PROPOSED USE OF.BUILDING CHECK 80.50
I hereby affirm that there is a construction lending agencyCHANGE PQQ
for the performance of the work for which this permit is -
issued(Sec.3097,Civ.C.). ('y�
Lenders Name PROPOSED MAX. OCG _ OOOO—OOOl OJ/=i9/OLl
Lenders Address /` i y pe4Vl
70, V ` 7
I certify that 1 have read this application and state that the PERMIT FEE O AM &h
above information is correct. 1 agree to comply with all County ISSUANCE FEE iJ SQ
ordinances and State laws relating to building construction, '
and hereby authorize representatives of this County to enter TOTAL-FEE- Q -
upon the above-mentioned property for inspection purposes. SEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
\/, , 5--_ 2J41'?S �
VSignature of Permittee Date ,