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jQVC;+RKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES B ILDING 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 M/77 XARa,
❑ Certified copy is hereby furnished. BUILDING LOCALITY
ADDRESS
F1
Certified copy is filed with the county building inspection r NEAREST
department. LocwLITY fd CROSS ST.
Date Applicant NEAREST l DISTRICT NO. 0OUP TYPE PROC� ED BY
CROSS ST. ALL 5^ /1 CONST.t /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ♦ )V/
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY
ND. (CIRCLE) STATE MAJOR SECO LOCAL d
•ar• NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE Z NE 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 O
permit is issued, I shall not employ any person in any manner OWNER �` U
so as to become subject to the Workers' Cott_pensation Laws. MAIL OCCUPANCY GROUP. LU
ADDRESS CL
Date Applicant
TE
NOTICE TO APPLICANT: If, after making this Certificate of CITv rvo �� — 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 0 GEOLOGY INSPECTION C1 No Spec. Knowl. ❑
deemed revoked. Panic DeVIC@S ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
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 PROVIDED
+ •
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 INSPECTOR'S
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES GNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
1 hereby affirm that, I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
NO. PARKING 9 0 A
ness and Professions Code): SPACES PROVIDED 2��
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PROPOSED USE OF BUILDING • • 8 Q 8
CONSTRUCTION LENDING AGENCY p =
• • . 8Q50
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.). 3_$5
Lender's Name - PROPOSED MAX. OCC. 0 O
Lender's Address PERMIT FEW V
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 (J
ordinances and State laws relating to building construction, TOTAL FEE
and hereby authorize representatives of this County to enter
,p,qn the ab e-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7
I Signature of Per it a Date