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WokKERS'COMPENSATION llECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affirm that I have certificate of consent or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,,or
a certified copy thereof(Sec.3800,Lab.C.)
BUILDING
Policy No. Company FOR APPLICANT TO FILL IN
ADO KESS
❑ Certified copy is hereby furnished. BUILDING
LOCALITY LOCALITY T`
ADDRESS
Certified copy is filed with the county building inspection NEAREST
department. LOCALITY CROSS ST. Cv
Date Applicant NEAREST DISTRICT NO. G OUP ITYPE PROCES D BY
CROSS ST. O V -//may -� CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J v U
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY }
NO. CIRCLE STATE MAJOR SECON LOCAL d
NO. OF SLOGS.
(Tills SCCtIOn need not be completed if the work involved TRACT Oa� NOW ON LOT USEZONEF��
CONDITIONS V
by the permit is for one hundred dollars (S100) or less.) USE of
SIZE OF LOT '— EXISTING BLDG. —/
I certify that in the performance of the work for which this Q
permit is issued, I shall not employ any person in any manner OWNER _ U
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP F W
ADDRESS �' d
Date Applicant U)
TEL.
NOTICE TO APPLICANT: If, after making this Certificate of CITY G- No. 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 or this permit shall be TRAILER USE GEOLOGY INSPECTION
❑
deemed revoked. 11 No Spec. Knowl.
Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (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 O
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE DATE
Ell am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer SIZE OF NO. OF j INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES r SIGXXATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
d- D 0A ,/
NO.OF EXISTING BuILD1�1 S
HOME OWNER-BUILDER DECLARATION ON LOT AND USE # 0 0 0 0 3(]
I hereby affirm that I am exempt from the Contractor's •,I 0 0 8 Vt 5 0
License Law for the following reason (Section 7031.5., Busi-
ness and Professions Code): NO. PARKING p
a 5 O U
I, as owner of the property, will do the work and the SPACES PROVIDED O O O 8
structure is not intended or offered for sale (Section 0614-85
7044,Business and Professions Code). PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY o
I hereby affirm that there is a construction lending agency -z,;
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 PERMIT FEE 01 Uo
I certify that I have read this application and state that the 0
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, TOTAL FEE
Td It eby authorize representatives of this County to enter toc�
G ab enti ed property for inspection pu poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee D e