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DECLARATION 76M444 MISCELLANEOUS
� o p At p qq pp g pp
a + " CE 875 (2-80) MISCELL�aNEOUS APPLICA 9 �ON
I herigby, )that
Ihave �'certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure`,,or , ate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy Nat CompanyFOR APPLICANT,TO FILL IN BUILDING
ADDRESS
❑ Certified copy Is hereby furnished BUILDING LOCALITY
ADDRESS
rY1 0 610
,❑ Certified copy is filed with the county,building Inspection NEAREST,
department. LocwLITY CROSS sT
Date Applicant NEAREST, P DISTRICT GRQUP TYPE / P ESSED BY
CROSS ST // �' CO
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �i lC V
COMPENSATION INSURANCE DEscR/PnoN LO T'NO BLOCK MAv HIGH WAV
ND 1, (CIRCLE) STATE MAJOR SECOND LOCAL tl
NO OF BLDGS 0
(This'section need-not be completed-if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for otfe hundred dollars-($100) or less.)
r+ U S E'O F
SIZE OF LOT EXISTING BLDG '
I certify that in-the performance of the work for which this 1 0
permit is Issued, I shall not employ any person`in any manner OWNER
so as to become subject'to the Workers' Compensation Laws MdIL r OCCUPANCY GROUP �j o�_ W
ADDRESS 6
Date Applicant G Z
NOTICE T-O APPLICANT If, after making this Certificate of clrY'Lfe Ct T L OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATI N 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 ' No Spec. Knowl. ❑ '
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ,Panic Devices
El
I hereby affirm that I am licensed under provisions of,ChapterSAFETY PERMIT, f (LIST ITEMS BELOW) NO o'F Exirs
9 (commencing with Section 7000),of Division 3 of the Susi-
, Busi-
ness and Professions Code, and my license is in full force and QS C r_ �� PARKING. s
effect SPACES REq'D O PROVIDED D
c
Liense Number Lic' Class �' -£' u- imi-v
` - - - - LIMITED TIME USE- '
Contractor Date E " DATE DATE'
El I'am exempt from the licensing requirements as I am a
FROM 'TO
licensed architect or a registered professional en"ginee- SIZE OF` NO OF INSPEC oR's
acting in my professional capacity (Section 7051, Bus- EXISTING-BLDG. ��� a ,Z4 5 TORIES, SIG URE
mess and Professlons•Code) PRESENT USE OP ISUILDINGy-yl�•- FINAL APPROVAL
Llc or Reg.No Date I ���r� `
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, Buss- '7' :i =
Hess and Professions Code) P PARKING
S
_ SPACES PROVIDED - { •1••��•3 I�
❑ I,`as owner of the property, will do the work and the
structure is not intended or offered for sale (Section TS-
7044; Business and Professions Code) -. - f— 00
PROPOSED USE OF BUILDING ,
CONSTRUCTION LENDING AGENCY "Il` -, j
I hereby affirm that- there is a construction lending agency '' �' t
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 -
r PERMIT FEE �� - • JfJ
I certify that I have read this application and'state that the' �O
above Information is correct I agree to comply with all County ISSUANCE FEE
ordinances and-State.laws relating'to' building construction,
TOTAL FEE
and hereby authorize representatives of'this County to enter,
upon above- entioned prop for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE' ;
b
ature of Permittee DatqJ