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WORKERS'Y:}OMPENSATION DECLARATION 75M444 MISCELLANEOUS APPLICATION {�
i- CE 875 (11 84) LJ
I hereby affirm that i have a certificate 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.Q.
Policy No. Company FOR APPLICANT TO F I LL I N BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING LOCALITY
ADORES$
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST. G
Date Applicant NEAREST �, (- DISTRICT NO. G U TYPE PRO $SED RY
CRO55 ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL - U ✓
COMPENSATION INSURANCE DEscRlpnory Lor No. BLOCK MA ICRwa
Na.P (c, LEI STATE MAJOR SE NO LOCAL
b. OF BLOGs.
(THIS section need not be completed If the WOIk InVO1Ved TRACT z IN
NOW ON LOT USE ONE SPECIAL CONDITIONS
by the permit is For one hundred dollars ($100) or less.) - usE of
512E OF LOT EXISTING BLOC
I certify that in the performance of the work for which this o
permit is issued, 1 shall not employ any person in any manner OWNER
04
so as to become subject to the Workers' Compensation Laws. �+ D _CAAJJ/ . OCCUPANCY GROUP -3
wo ow Ess / � ! �..5//�C.�(_-t `
Date Applicant _ - '-_�'- :• \ w
NOTICE TO APPLICANT: If, after making this Certificate of crcv Lei Ll TEL,
r OCCUPANT LOAD
Exemption,'you should become subjectto the Workers' APPLICATION FOR EX IT HAR DW AR E:
Compensation provisions of the Labor Code, you must forth- -
with comply With such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. El
deemed revoked. El
LICENSED CONTRACTORS DECLARATION occupwrvcv 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 EXITS
ness and Professions Code, and my license is in full force and / �t I
effect. S /V PARKING Ra Wn —FIR OVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE U,.TE
I am exempt from the licensing requirements as I am a p FROM
licensed architect or a registered professional (engineer saE IF +aJ �/9'� 'No. of INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. � ' I VV STORIES SIG ATURE
iness and Professions Code). FINAL APPROVAL /ff
PRESENT USE OF BUILDING
Lic.or Reg. No. Date
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- z 1 3 G 4 A
ness and Professions Code): NO. PARKING
I, as owner of the property, Will the work and the
structure is not intended or offered
SPACES PROVIDED
d for sale (Section •\ tiN, !, ' ._•,,�> .a V
7044,Business and Professions Code). \ \
N 68 PROPOSED USE OF BUILDING '�-`��,5`\`\\I \ \\\�` '_\ y°Vsx I 5 U
CONSTRUCTION LENDING AGENCY \ \ •,1.-L �`$•$
I hereby affirm that there is a construction lending agency �.\�_1N.'rJ� �\� \�;a\�s _0-t
for the performance of the work for which this permit is - --' s J• �'
issued(Sec. 3097,Civ.C.).
Lendeti s Name - -
PROPOSED MAX. OCC,
Lender's Address �. J J � �3 �"'F� -t d•t y'`
PERMIT FEE
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,
and hereby authorize representatives of this County to enter TOTAL PEE S -
u on the above-mentioned Top try for inspectio Aur ses.
J SEE REVERSE FOR EXPLANATORY LANGUAGE
I Signat e of Permittee L Ole