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WORKERS'COMPENSATION DECLARATION
CE 875(11-84) MISCELLANEOUS APPLICATION
CE 875
I hereby.affirrtificat I have a certificate of consent to c self COUNTY OF LOS ANGELES j BUILDING AND SAFETY DIVISION
'fl
insure, or ra certificate of Workers'Compensation Insurance,or �� J." .
a certified�bpy thereof(Sec. 3800,Lab.C.).
Policy No. CompanyFOR APPLICANT TO FILL IN Bu 1LDING
ADDRESS
K.
ESS
Certified copy is hereby furnished: aonRess i ' LOCALITY do C
0 Certified copy is filed with the county'building inspection LOCALITYNEAREST
U:11-J,
department. TQM l� CS CROSS ST.
"Date ApplicantNEAREST DISTRICT NO. GROUP TYPE PR CESSED BY
` CROSS ST. , CONST. '
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
.. I - - No. (CIRCLE) STATE MAJORSE CO ND LOCAL
NO. OF BLDGS.
(This section need not be completed if the'work'involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
SIZE OF.LOT
by the permit is for one hundred'dollars ($100) or less.) _ USE
OF'
EXISTING BLDG.
I certify that in the performance of the work for which this C/ a�
permit is issuedI shall not em S-'
.p , employ y an y person in any manner owriER SU�i(1 � e� S�,
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP 3 0
ADDRESS • T� 94 V
Date Applicant LU
NOTICE TO APPLICANT: If, after making this Cert
rE OCCUPANT LOAD
cate of CITY T - C1�� NO —�'g3 N
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 or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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 ander PARKING effect. _ SPACES REq'D D PROVIDED D
License Number Lia Class
LIMITED TIME USE
Contractor Date - - DATE DATE
I am exempt from the licensing,requirements as'l am a -, FROM: TO:
licensed architect•.or a registered professional engineer SIZE OF NO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). 1 ��J Z Jk, FINAL APPROVAL
PRESENT USE OF BUILDING -
Lie.or Reg.No. Date - -
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1iI-`_•! va
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi i i.i`�_
ness and.Professions Code): NO. PARKING
SPACES PROVIDED H�-I �O.I� - �.
I, as owner of the property, will do the work and the HUT :34 � �
structure is.not intended or offered for sale (Section _
7044,Business and Professions Code). l:t�k_rt
PROPOSED USE OF BUILDING n-1i
CONSTRUCTION LENDING AGENCY titd(I=
I hereby affirm. that there is a construction lending agency.. �. �1 j•�
for the performance of the work for .which this permit is
issued(Sec. 3097,Civ.Q. 1 S To
Lender's Name rr; -'
PROPOSED MAX. OCC. 4C`aCS 1'`11
i eC '
Lender's Address I 1
'PERMITFEE Q '
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 FEE
upon the above-mentioned�.ue�er4 spection purposes.
MS 4 SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date I T