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WORKERS'COMPENSATION DECLARATION 70M444
CE 876 (2-80) MISCELLANEOUS APPLICATION
i gur, o affirm that I have ■ certificatempen of consent to ,elf COUNTY OF LOS ANGELES BUILDING AND SAFETY DMSION
insure, or a certificate of Workers'Compensation Insurance,or -
a certLfted copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN wocw��� a
Certified copy is hereby furnlahed. 'BUILDING TLocwLirY .
D ADDRESS /
Cartlfled copy V filed with the county building inspection NEAREST
AAW
department. OCALITY CRO/91 ST.
Date_ Applicant ARESt / DI■TR�T Oj,O TYPE PRO ■D ■Y
RO/■ ST. f/+ fU( CONS
CFRTOCATE OF EXEMPTION FROM WORKERS' LEGAL 1
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP rI■rlwwr
NO. Or BLDG/. IRCLK) STATE MAJOR SECOND OCAL
(This
�� ^
li„” aectl0n need not be completed if the wOdc Involved TRACT NOW ON LOT USE ZONE /P[DIAL CONDITION) ]U{
by the permit is for one hundred dof)us ($100) or leu.)
USE OF /^�_ cc
■IZEOF LOT EXISTING BLDG. /V/
I certify that In the performance of the work for which this Q
permit is issued, I shall not employ any person Ln any manner 14NER
so as to becopio subject to the Workers' Compenutlon Laws. wIL / OCCUPANCY GROUP LL
A DR[./
Date Applicant
NOTICE TO APPLICANT: If, after.making thb.Certificate of LO CITY no. OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICA ION FOR EXIT HARDWARE:
with comply with such provtslona or thlr permit ellall be TRAILER USE GEOLOGY INSPECTION No Spec. Know). ❑
deemed revoked. . ❑
LICENSED CONTRACTORS DECLARATION
OCCUPANCY INACTION Panic Devices
I hereby affh-In that I am licensed under provisions of Chapter SAFETY PERMIT [�
9 (commencing with Section 7000) of Divislon•3 of the Bust- (Cllr ITEMS BELOW) XO..OF EXITS
near and Profesaions Code, and my license Is in full force and PARKING.
effect. REVD P-
.-IDK-SPACES
LicenmNumber LIc-Class LIMITED TIME USE
Contractor Data
pwrl DAPI
Pwov I roI
ElI am exempt from the licensing requirement; as I am ■
licensed architect .or a registered, professional engineer PIZE OF No. OF N Ecro R'■
acting Ln my professional capacity (Section 70511 Bus- EX TING BLDG. /TORIES NATUR
mesa and Professions Code). FINAL APPROVAL
RESENT USE OF BUILDING `
Lic.or Reg.No. Date T 0 y`�
� f1�
STING
HOME4DWNER-BUILDER DECLARATION 014 of tXI LOT AND fE USK BUILDINGS
ON
#:1 1
I hereby affirm that. I am exempt from the Contractor's e¢Z Q
License Lbw for the following reason (Section 7031.5, Bus[- a
mesa and PTofpsslons Code): NO. PARKING
SPACES PROVIDED
1, ai owner of the property, will do the work and the
atructure Is not Lntended or offered for sale (Section
7044., Business and Professions Code).
ROPOSED U/E OP BUILD ING
CONSTRUCTION LENDING AGENCY
I hereby afllrm that there L# a construction lending agency
for the performance of the work for adilch this permit is
issued (Sec. 3097,Civ.C.).
bender's Name PROPOSED MAX. OGC. -
Lender's Address FERMIT FEE
I certify that I have read this application and "to that the
above information is correct.I agree to comply with all County ISSUANCE FEE
ordLaancei and State laws relating to building construction,
.and hereby authorise representatives of this ounty to enter TOTAL Fa:E
he abova n opert or ectlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
lure of Permittee Data J