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I'Wo 1fS'COMPENSATION DECLARATION CE 878(11-B4) M ISCELLANEOUS APPLICATION
by#Saffirm that I have a certificate of consent to , COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
or a certificate of Workers'Compensation Insurance,or
a cort�fiad copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN R
1D1MI 'J
[Ss
FICertified copy is hereby furnished. Dl�ei.; { I
Certified copy Is filed with the county building Inspectiont N[AR[eT
department.
QALITY CRo/■ ST.
Date Applicant SAR[ST DISTRICT O. 6 U CON =EO
■Y
OSS ST. CONST.
CERTIMQATE OF EXEMPTION FROM WORKERS' LKGAL I
COMPENSATION INSURANCE D[SCRIPTI OR LOT NO. ■LOCK NAP HMHYAY
No. (CIRC) ■TAT[ MAJOR ■<Q D LOQAL
ry,�' NO. OF BLDG■.
Crhll section need not be completed If the work involved TRACT NO[I ON LOT U■ ON ■P[QLAL CONDITIONS
by the permit is for one hundred dollm ($100) or lees.) USE of
BIZ[ OF LOT [XI/TING ■LM0.
I certify that in the performance of the work for which this o
permit is issued, I giall not employ any person in any manner N[R — v
so as to become subject to the Workers' Compensation LawL IL OCCUPANCY GROUP' �. o
R[■■ � I
Date Applicant w
NOTICE TO APPLICANT: If, after makC
lnv this erti$cate of -Y l M[ = OCCUPANT LOAD ccn
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 oI this permit shall be TRAIL[R U/[ ❑ G[OLOGY INSPECTION ❑ No Spec. Know[.
deemed revoked.
LICENSED CONTRACTORS DECLARATION occurwNCY IN•P<CTION{] Panic Devices
I hereby affirm that•I am licensed under rpr}i,ov�iaions of Chapter ■ARTY P[RYrr LIST IT[M■ ■[Colt)
9 (commencing with Section 7000) of DMIIOII 3 of the Bud ❑
No. of [xIT■
Deas and Professions Code,and my license is In full force and
PA RKIN6 Rtq'D PROVID S:D �— I
/PAC[■ J
Lim Number LIa Clm LIMITED TIME USE
Contractor Date AT. DAT<
❑ \ I, F110N1 TOI
I am exempt from the lid requirements as I em a
licensed architect OI a registered professional engineer SII[ OF No. OF IN■P[QTOR
acting in my professional Capacity (Section 7051, Bus- [xl/TING NLD 6. ■STORMS ■IGNATURK
Imss and Professions Code). FINAL A PP IR �vJ
Lic:or Reg.No. �� PR[■[NT u/[ or ■UILDIN J
HOME OWNER-BUILDER DECLARATION NO. OF [XISTING BUILDINGS
ON LOT AND US[
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
and Professions Code): 140. PARKING
I, as owner of the prowill do the work and the ePwc[/ PRovID[D
structure Is not intended or offered for sale (Section 8 6 Q,2 A
7044,Business and Professions Code).
PROPO/tD U/[ OF BUILDING # o D o D 3 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency
for the performance of the work for which this permit is I D u 8 (q 5,0
Issued(Sea 3097,Civ.C.).
Lender's Name o o 0 8 (15.0 6
PR OPO■[D MAX. OCC.
Lender's Address
PERMIT FH[ ,� 2 2 2 —8 7
I certify that I have read this application and state that the
above information Is correct.I agree to comply with art County ISSUANCE PHE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the al>ovementiq p prty for inspection purposes_
7 SEE REVERSE FOR EXPLANATORY LANGUAGE
e of Permittee D&_
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