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tV P3.�RS'COMP NSATIONDECLARATION CE 8875 75(11-84) MISCELLANEOUS APPLICATION �� I
i' CE
Ihereby 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 BUILDING11
//�� ADDRESS A
Certified copy is hereby furnished. BUILDING L/ pZ� v����� j//" LOCALITY
ADDRESS / „✓C
Certified copy is filed with the county building inspection LOCALITY TC Al I'T NEAREST
department. CROSS ST.
Date Applicant NEARESTDIS; T
!) ` Np/ TYPE PR SED BY
CROSS ST. S tL UVA�/ CONST_.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP IG Rw Av STATE: MAJOR sEco LOCAL
NO. OF BLDGS. � NO. (CIRCLE) '
(This section need not be completed if the work involved TRACT /s-o (? NOW ON LOT US`s ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
US
OF /J J
I certify that in the performance of the work for which this SIZE OF Lor EXISTING BLDG. ���CCC CD
n 0
permit is issued, I shall not employ any person in any manner OWNER I-OS l7ICZ rE LES 14D1-IF DI•JNEe—S fiSSOC .
so as to become subject to the Workers' Compensation Laws. MAILOCCUPANCY GROUP o
ADDRESS Li 1 z-5–/J . -KRUFF/it9t.J vC r-
Date Applicant L_�I
NOTICE TO APPLICANT: If, after making this Certificate of cIrY�EA PLE C7e�,CA NOL ` -�� OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions oI this permit shall be TRAILER USE ❑ 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 ❑ (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 I
effect. PARKING REQ'D E� PROVIDED
SPACES
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 SIZE OF NO. OF INSPECTORS
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES (� SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING l'�(7�M J FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 6 4 2 0'A
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's # 0,0 0 030..
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No. PARKING o 0 80.50.
I, as owner of the property, will do the work and the SPACES PROVIDED `0 0,0 =
structure is not intended or offered for sale (Section 8 0.5 0`�
7044,Business and Professions Code). 0 2 8 2 8 7
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING r
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.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I
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 herebyaythorize representatives of this County to enter TOTAL FEE
Is
upon thebo a mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur of Eumittee Date