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WORfERSthat I have
TIONaIcet DECLARATION CE 875 MISCELLANEOUS APPLICATION {�
CE 44 (71-64) Ll
I he%by affirm that I have a s'Compensation
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.).
Policy No. Company FOR APPLICANT TO FILL IN noon sNGSS
2,
Certified copy is hereby furnished. BUILDING
Ag�p� \;,�^
O DR Ess Fg/� Ua0 LOCALITY
FICertified copy is filed with the county building inspection LOCALITYt NEAR,ST
department. CROss ST.
Date Applicant NEAREST I r I
E I,C �r( /`� 019TRICT O. GRRROOOyp TYPE PRO SEO BY
CROSS .T. I ✓�L CONST.1/
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ( 'AM/l V -
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK AP ,GRWA
NO. OF BLDG S'
n0. IC,HCLHI STATE MAJOR SEC ND LOCAL
(This section need not be completed If the WO[k InVO1Ved TRACT NOW ON LOT / US ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) 0S of /1�5
SIZE OF LOT EXISTING BLD G. /1 y
I certify that in the performance of the work for which this
permit is iisued, I shall not employ any person in any manner OWNER 1, E m / o
m as to become subject to the Workers' Compensation Laws. GROUPz m
MAIL OCCUPANCY Date Applicant ADDRESS
U
NOTICE TO APPLICANT: If, after making this Certificate of CITY ' �� T L. ` 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 sl1all be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. E] ❑ No Spec. Know[.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
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 EXITSEl
ness and Professions Code, and my license is in full force and ,
effect. PARKING pE0'D E= PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
El PRom:
I am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer SIZE OF NO- OFINSPBCTOR's
acting III my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 51 wruwE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS -
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
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
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 —4494,9A
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). '# a e s e 3 O
Lender's Name - p
PROPOSED MAX. OCC. I e o80.50
0. C
U J O
Lender's Address
I certify that I have read this application and state that the PERMIT FEE I 2
'a a e$ (15.05
above information is correct. I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, -07, 02 -86
and hereby authorize representatives of this County to enter TOTAL FEE IS
upon a abov bone ropetty fg,�rrUiciion pur .
`//� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date