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WORKERS'COMPENSATION DECLARATION CE8454(11-84) MISCELLANEOUS APPLICATION
I lureaffirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,, o or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING D /
ADDRESS ��-
Certified copy is hereby furnished. BUILDING 71 e� S'�� LOCALITY
ADDRESS
Certified copy is filed with the county building inspection LOCALITYe—r), /� C�� cRoss ST. �/(� �_
department.
Date Applicant NEAREST O ^,� DISTRICT NO. G UP TYPE CESSED BY
CROSS ST. A CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP. _ HIGHWAY
NO,I� �Z,3(CIRCLE) STATE MAJOR SECOND L AL
NO. OF BLD S.
(This section need not be completed if the work involved TRACT f NOW ON LOT USE ZONE SPECIAL CONDITIONS
by .the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT �' 150 EXISTING BLDG. � 1
I certify that in the performance of the work for which this O
permit is issued, I shall not employ'any person in any manner OWNER c) \J_BV p, K 4igyvivne s>
so as to become subject to the Workers' Compensation Laws. OCCUP
_ ANCY GROUP
MAILO
ADDRESS
X3:1
Date Applicant IM71
/rV
I
T
EL. OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY p-��J -e NO. � N
Exemption, you should become subject to the Workers' z
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. Know].
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (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 �j
• U c_5 ` Q S PARKING
effect. SPACES REQ*D � PROVIDED
License Number Lic. Class o
LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OFNO. OF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES ! . SI NATURE
iness and Professions Code). T
Lic.or•Reg.No. Date PRESENT USE OF BUILDING USS I fin„ FINAL APPROVAL ✓ ✓fdjJ
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
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-
ness and Professions Code): NO. PARKING \
\•
I, as owner of the property, will do the work SPACES PROVIDED
and the
structure is not intended or offered for sale (Section
�T
7044,Business and Professions Code). , `•� \,� gg, � r•
PROPOSED USE OF BUILDING �•A t`` `Z 54,3-/ A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency ;:� # o e e• AL3 0
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). , Y I • • 8"0.5 0
Lender's Name 8 0 5,0 5
PROPOSED MAX. OCC. e • O
Lender's Address
�8 L
V
I certify that I have read this application and state that the PERMIT FEE 09. 1 5 V
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and liereby authorize representatives of this County to enter TOTAL FEE J�
on the abo e-mentioned p rty for inspection purposes.
6 SEE REVERSE FOR EXPLANATORY LANGUAGE
• Signature of Permittee ate •