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WORKERS'COMPENSATIONDECLARATION CE 8454 (280) MISCELLANEOUS- APPLICATION
I 1%ereby 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. C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING _
ADDRESS ^
❑ Certified copy is hereby furnished. BUILDING LOCALITY
-- ADDRESS L�f. G��t�
Certified copy is filed with the county building inspection / NEAREST
department. LOCALITY !�C �/ CROSS ST. � �
Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROC SED BY
CROSS ST. (lJ J!/ CONST.�/
CERTIIFICATE OF EXEMPTION FROM WORKERS' LEGAL �¢v
COMPENSATION INSURANCE DESCRIPTION LOT NO.• BLOCK MAP ad63 „I°,,,n,Ay }
STATE MAJOR SECOND LOCAL '
This section need not be completed if the work involved NO. OF LOT USE ZONE SPECIAL CONDITIONS 0
OL
( P TRACT NOW ON LOT ,
by the permit is for" one hundred dollars ($100) or less.) USE OF ( OU
SIZE OF-LOT 'EXISTING BLDG.
I certify that in the performance of the work for which this 0
permit is issued, 1 shall not employ any person in any manne � 11 o
so as to become subject to the Workers' Compensation Laws. MAILER `L N = OCCUPANCY GROUP �.� W
ADDRESS'�i 7;. C �."'-r
Date Applicant —� TEL: to
NOTICE TO.APPLICANT: If, after making this Certificate of' CITY t NO.a/3 x23%6'3y/p OCCUPANT LOAD z
Exemption, you should become subject to the Workers' APPLI ATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TRAILER USE E] 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 PERMIT Q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect, _ SPACES REQ'D E:= PROVIDED O
License Number Lic:Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer slzE of NO. OF a'r7 N cod .
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES t i SIG
lness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
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
SPACES PROVIDED
I, as owner of the property, will do the work and the 9 2 9 Q 5 A
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 0
PROPOSED USE OF BUILDING � # 0,.0,0 O 3
CONSTRUCTION LENDING AGENCY 2 ° ° 6 2,5 0
I hereby affirm that there is a construction lending agency ,
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).- ° ° ° 6 2 5 0105
Lender's Name PROPOSED MAX. OCC. 0 2 7 CJ
0, >�O 2
Lender's Address PERMIT FEE _ 7
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 Sol,
ordinances and State laws relating to building construction,
ereby authorize representatives of this County to enter TOTAL FEE I W/>4 ,s'0 .
u on the above-men Pned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date