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jORfRS'COMPENATION DECLARATION 6 -MISCELLANEOUS QP LIC 4IONCE 87 (2-80) .
I hereby 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 CompanyBUILDING
FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is hereby furnished Bu LDIN5 FOCALITY
❑ Certified copy Is filed with the•county building inspection' _[ NEAREST
department. - LOCALITYCROSS-ST.
Date Applicant NEAREST DISTRICT NO G ,U TYPE PRO E SED BY
C
ROS ST ' U (I•� CONS'( /
CERTIFICATE OF EXEMPTION'FROM-WORKERS' LEGAL 'J V
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAYSTATE MAJOR SE ND LOCAL a
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NO (CIRCLE)
NO OF BLDGS _
(This section need not be completed if the work involved' TRACT NOW ON LOT USE OFcIALNE CONDITIONS O
by the permit is for one hundred dollars, ($100) or less.) _ USE of
• SIZE OF LOT EXISTING_BLDG. r cc
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER O
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP W
ADDRESS d
Date Applicant - to
TEL Z
NOTICE TO APPLICANT If, after making this Certificate of CITY ClNO. 44 6 L77 I OCCUPANT LOAD
Exemption, -you should become subject to the Workers' APPLIC TION FOR EXIT HARDWARE.
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions Or this. permit shall be TRAILER USE GEOLOGY INSPECTION Cl Spec. Knowl: ❑ '
deemed revoked
Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is In full force andPARKING.
effect. SPACES REq'D PROVIO ED
License Number LIc.Class `�' SA714 AP,60 M i INI — LIMITED TIME USE
Contractor Date — — �I• GATE DATE
❑ I am exempt from the licensing requirements as I am
licensed, architect or a registered professional'engineer SIZE OF NO OF FROM To
`
a
INSPECTOR'S
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL /
PRESENT USE OF BUILDING
Lic.or Reg No Date—
HOME
ate 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
❑ 1, as owner of the property, will do the work and the
structure Is not intended or offered for sale (Section Jr 2 �' A
7044, Business and Professions Code). PROPOSED USE OF BUILDING # o,o,o o 30
CONSTRUCTION'LENDING AGENCY 'I o•o 8 a 5 Q
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is o eto 80,506
Issued(Sec 3097,Civ C)
Lender's Name
PROPOSED MAX. OCC O &0$ 8 6 _
Lender's Address PERMIT FEE ' -
I certify that I have read this application and-state that the L
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 I
TOTAL FEE
upon the above-mentioned property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
t,
Signature�of Permtttee Elate