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WORKERS'COMPENSATIONDECLARATION CES75MISCELLANEOUS APPLICATION'
CE 44 (2-80) '
I jffirm that I have a certificate of consent to Self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or acc�ificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800, Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is hereby furnished. Bu LR .. �O I /)(� JT LoeALITY
❑ AD°R IN (2 F+ I f� t v
Certified copy is filed with the county building inspection ('� NEAREST
department. LOCALITY LITY TETI)P UI `i CROSS ST.
Dat2 - Applicant - NEAREST )1 c'((��1,IST 1�1y/\��_�yJJ 1•• l Mry� 1() DISTRICT NO. G UP TYPE PROC�ESSEO By
• - CROSS ST. S VuYR\T� ROSEIrrC(�Q �f {3(� CONSj./
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL v ` ✓
COMPENSATION INSURANCE DESCRIPTION LOT rvo. - eLocK Meo ICI IRCLL.E)R CL
) STATE MAJOR SEC 4NO LOCAL a
(('li NO. OF BLDGS: O
(This section need not be completed if [s work. involved TRACT I a a Now ON Lor USE zorvE. sPEcrAL conolnorvs
by the permit is for one hundred dollars (5100) or less.) ( EXIBE OW F
' F LOT (ry^ � 45USE
YMp.' U
IN BLDG. e
I certify that in the performance of the work for which this T _ Q
I.-
permit is issued, I shall not employ any person in any manner Ow NER :WQN�1� + F9,PV0 L l�U � f—
so as to become subject to the Workers' Co pensation Laws. / n OCCUPANCY GROUP U
llate Applicant ADDRess �'Q�SC+ •T� d
v U)
NOTICE TO,APPWCANT: If, after.making this.Certificate of CITY &YrvVeI .0..L.(67MM4 OCCUPANT LOAD Z
Exemption, you shouldbecome 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 USEGEOLOGY INSPECTION '
deemed revoked. El ❑, NO S{)OC. KnOW�. E]
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi-
El
ness and Professions Code, and my license is in full force-and PARKING•
effect. SPACES REO'O PROVIDED
[� O
License Number Lic.Class �TJ� 1`J
t.�If� r1, , LIMITED TIME USE
Contractor - Date W 3T �p �.py 0 '``r 1N n AT. DATE
❑ 1 am exempt from the licensing requirements-as I am a l q S '" I$ l * 1344 % pry
licensed architect or a registered professional engineer SIZE OF '.y.C��+l✓- rvo. oP INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. 1 4Y Lp STORIES SIG ATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING /.
Lie.or Reg.No. Date—
HOME
ate HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS '
ON LOT AND USE
I hereby affirm that 1 am exempt from the Contractor's .
License Law for the following reason (Section 7031.5, Busi=
ness and Professions Code): NO..PARKING ,
SPACES PROVIDED O
El1. as owner of the property, will do the work and the 2
structure is not intended or offered for sale (Section - - # e 3 0
7044, Business and Professions Code). PROPOSED USE OF BUILDING -
U
CONSTRUCTION LENDING AGENCY
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.C.). -
Lender's Name -
PROPOSED MA%. 00C. '
1.
Lender's Address PERMIT FEE c
I certify that I have read this application and state that the �24 0o
ISSUANCE FEE J (4f g)}�d —q-&/T
above information is correct. 1 agree to comply with all County I '
ordinances und'State laws relatinglto building construction, -
TOTAL FEE
and hereby authorize representatives of this County to enter
upon the atinv,,-I entio(n�ed.�property for inspection purposes. . SEE REVERSE FOR EXPLANATORY LANGUAGE
SiSin +_F Xyl nJ .a --
gnatureotl rmiitee rttee Date ,