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WORKERS'COMPENSATION DECLARATION 76M444
' ,a CE 875 (280) MISCELLANEOUS APPLICATION , {�
I hereby afc6rti that I have a certificate of consent nc self COUNTY OF•LOS ANGELES BUILDING AND SAFETY DIVISION �J
insure, or e'certificate of'Workers'Compensation Insurance,or ^ . .�" ,
a certified copy thereof(Sec' 3800, Lab C)
Policy No s Company
BUILDING
It. FOR APPLICANT TO FILL IN J
sIt. r ADDRESS L 1 ,
❑ Certified copy Is hereby furnished BUILDING h L LOCALITY //•g
ADDRESS T.
❑ Certified copy!s tiled with the county building inspection NEAREST
department ° LOCALITY
, CR+OSS ST
I I NEAREST 4 DISTRICT NO G UP TY PROC�E SE BY `
Date Applicant L� _� '\ 'co sr
CROSS ST . (J 1/
CERTIFICATE OF EXEMPTION-FROM WORKERS- LEGAL + ` _
DESCRIPTION, LOT NO BLOCK - MAP HIGHWAY +-
COMPENSATION INSURANCE STATE MAJOR sEc D LOCAL '�a
INSURANCE,
.^ NO OF BLDGs . NO (CIRCLE)
(This section need not be completed if`the Work involved TRACT / > > rj fi NOW ON LOT USE ONE SPECIAL CONDITIONS O'
by the permit is for one hundred' dollars ($100) or less) _
r USE'OF ' � r y
SIZE OF LOT f� I / I�" EXISTING BLDG ��Y ` ' E* R
I certify that in the performance of the work for-which this , a O
permit is issued;I shall not employ any person in any manner, OWNER A,oj �G �� �� w r V}
• so as to become subject to the Workers' Compensation Lawn IMAIL , i OCCUPANCY}GROUP ' s s W
^ CL
ADDRESS CLv ` '1 t co
Date Applicant
NOTICE,TO'APPLICANT If, after making this Certificate of cITY' ��; _ NO L - OCCUPANT LOAD ?
^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 USED u GEOLOGY INSPECTION - No Spec Knowl r❑
deemed revoked c
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 0 i - Panic Devices ❑ _
I hereby affirm that I An'11ILensed under provisions of Chapter` Llsr I
SAFETY PERMIT [� (
9 (commencing with Section 7000),of Division,3 of the-Buse ITEMS BELOW) NO of EXITS ❑ ' _ "
ness and Professions Code, and my license is in full force and
PARKING
effect SPACES REQ D O I PROVIDED D
y pl 001
License Number Lic Class
} _ LIMITED TIME USE '
Contractor' Date Ac3020 . DATE DATE
❑ ,. - r Y ♦ • r •� FROM 1,• ` TO
' , t
I am exempt-from the hLensmg requirements as I am a Tj '
licensed architect Or a registered professional engineer SIZE OF NO OF 1 Iry ECTOR S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG 3 STORIES IG NATURE
mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL
Lic or Reg No Date P
HOME OWNER BUILDER DECLARATION NO OF EXISTING BUILDINGS
,ON LOT AND USE h
I hereby affirm-that I am exempt 'from the Contractor's
License Law for the following reason (Section 7031 5, Busi
r
ness and Professions Code) I' NO PARKING
❑
� SPACES PROVIDED .S I, as owner of the property, will do the work arid theJ 2 5 211111 `A
y�
structure Is not intended or offered for sale (Section
7044, Business and Professions Code) { r' y # • ? !T• 3,0PROPOSED USE OF BUILDING 1 M
CONSTRUCTION LENDING AGENCY _ n r - ;' {�' `�' .•t1 °• 8 Q 5 0,.
I hereby affirm that there is a construction lending,agenc'y '
for the performance of the work for which this permit,is r `o 8 0.5 0,5
issued(Sec 3097,Civ C
Lender's Name
PROPOSED MAOCC
0 ' L860&
i t
Lender's Address" PERMIT FEE `I
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
ordinances and State laws relating to building construction, ITOTAL FEE . }
and hereby a�ithor repregentatives of this County to enter 2 e `
upon t e a ove eltione property for inspection purpo es ,SEE REVERSE FOR EXPLANATORY LANGUAGE
D
Signature of Permittee > Date
4—
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