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R ERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS
/� �� ®� APPLICATION
t o CE 875(1 1-84) 1�
hha.c that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insuiea,certificate of Workers'Compensation Insurance,or
a certified copy hlereof(Sec. 3800,Lab.C.).
Policy No. CompanyBUILDING
FOR APPLICANT TO FILL IN ADDRESS Q �� C
!'
'Certified.copy is hereby furnished. BUILDING {nI�,�- ) /�
1..?a ADDRESS Q Q}I,�G JQ �. G LOCALITY J/y ( " /,/.
Certified copy is filed with the county building inspection LOCALITY NEAREST III (�. [��rV S
4department. CROSS ST. LOt.Jw
Date _ Applicant NEARESTa DISTRICT GROUP ItYPE O ED BY
CROSS ST. CONS
CERTIFICATE OF EXEMPTION FROM.WORKERS' LEGAL L 1
C> COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOC
NO. OF BLDGS.
(This section need not be completed If the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF /� //`
SIZE OF LOT EXISTING BLDG. / ✓/
I certify that in the performance of the work for which this
0
permit is issued, I shall not employ any person in any manner OWNER CV L r C—>
so as_to b co e s ject to the W^o_rkers' Compensation Laws. MAIL OCCUPANCY GROUP Dc
/ ADDRESS � O
Date E Applicant VVWWWW L�
t'NOTI E O APP ICANT: If, after ma g this Certificate of clrY � No� �'`� OCCUPANT LOAD N
Exemption, you should become subject to the Workers' f z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be
• emed revoked.
TRAILER USE � GEOLOGY INSPECTION p No Spec. Knowl.
h_e
1. LICENSED CONTRACTORS DECLARATION occuvwNCY INSPECTION Panic Devices
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 and y(p� � p
effect. I W 1 vs--- PARKING
SPACES REQ'D O PROVIDED O
;License.Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
10 I am exempt from the licensing requirements as I am a 1 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, a SIGNATURE
0
iness and Professions Code). j.. �.....__..._...... FINAL APPROVAL � �-
PRESENT USE OF BUILDING 6+ 4''•
Lic.or Reg.No. Date _.,... ...6�°".N...............
..
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS O
ON LOT AND USE (J�'� b
I hereby affirm that I am exempt from the Contractor's ;:;
License Law for the following reason (Section 7031.5, Busi- �',} ] v� 51�
ness and Professions Code): NO. PARKING L E
I, as owner of the property, will do the work and the SPACES PROVIDED I.
---
structure is not intended or offered for sale (Section TOTAL 80 .50
7044,Business and Professions Code). `
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING CHECK 80.50c
I hereby affirm that there is a construction lending agency CHANE °00
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.Q.
Lender's Name OOM-0001 0, 110.9
PROPOSED MAX. OCC.
Lender's Address 5452 1 QM 9:06
Q ,
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
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the above-mentioeII property for inspectic p rposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
V
Signat of Permittee Date