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WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (11-84) _ `MISCELLANEOUS APPLICATION
I hereby arm 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.C.).
Policy No. CompanyFOR APPLICANT TO.FILL IN BUILDING
ADDRESS
FlCertified copy is hereby furnished. BUILDING ,e Q LOCALITY
ADDRESS 23/
Certified copy is filed with the county building inspection LOCALITYT��A l NEAREST
department. // ''!! CROSS sT.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE ��y CESSED BY
CROSS ST. �'. �- "� _� CONST. -�/'
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL !V/ 0,0
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NOOF LDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL
" .
(This section need not be completed if the work involved TRACT NOW ONBLOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
slzE of Lor EXISTING BLDG.
I certify that in the performance of the work for which this J _e) o
permit is issued, I shall not employ any person in any manner t OWNER
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS I'-'
Date Applicant /� L`��,
NOTICE TO APPLICANT: If, after making this Certificate of clr e'j No. OCCUPANT LOAD y,
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- AP (CATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PE MIT ❑. (Lis ITEMS H Low)
9 (commencing with Section 7000) of Division 3 of the Busi- i NO. OF EXITS
ness and Professions Code, and my license is in full force and A I
effect. O•L PARKING
SPACES REQ'D PROVIDED
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lie.or Reg.No. Date _
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE !s',r' 'rt•
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
El1, as owner of the property, will do the work and the sawces PROVIDED
structure is not intended or offered for sale (Section €'1 y L s3"-'- 5
7044,Business and Professions Code).
PROPOSED USE OF BUILDING HEDC ' --
CONSTRUCTION LENDING AGENCY _-
I hereby affirm that there is a construction lending agency -'`{•`I ` _�(ff
for the performance of the work for which this permit is _
issued(Sec. 3097,Civ.C.).
I..:w
Lender's Name
PROPOSED MAX. OCC. - nr=ivi
Lender's Address _.`;`e _ '' ''_•:
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE Z
ordinances and State laws relating to building construction, /
and hereby authorizepresentatives of this County to enter TOTAL FEE (v
n the ab I d property for inspection purposes._
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date