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WVRKERS'COMPENSATION DECLARATION CE 875(2-80) M I SC E L LA N O U S APPLICATION
I dhereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec.3800,Lab.C.)
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Policy No. Company FOR APPLICANT TO FILL IN puDREss J p (,cri-e
❑ Certified copy is hereby furnished. /' BUILDING��/_/] J�/ LOCALITY
SSfs�((i: �Y
ADDRE
❑ Certified copy is filed with the county building inspection NEAREST
department. LOCALITY J CROSS ST.
Date Applicant NEARESTD'STRICT NO. GROUP TYPE PRO ESSED BY
CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J 'j
O ESCRIPTION LOT NO. � BLOCK }
COMPENSATION INSURANCE NOP HIGHWAY STATE MAJOR SECOND LOCAL
NO. OF BLD6S. aU SO (cIReLC) q.
(This section need not be completed if the work involved TRACT / NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars (5100) 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/'6NER %`! U
so as to become subject to the Workers' Compensation Laws. AVAIL OCCUPANCY GROUP }�— IJJ
ADDRESS / y
Date Applicant
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NOTICE TO APPLICANT: If, after making this Certificate of CITYrIAI)k TEL.
No. OCCUPANT LOAD
Exemption, you should become subject 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 USEGEOLOGY INSPECTION
E] C] No Spec. Knowl.
deemed revoked.
OCCUPANCY INSPECTIO Panic Devices
LICENSED CONTRACTORS DECLARATION ❑
1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS a
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect. PARKING.
�� SPACES REQ'D PRONTO EO
License Number Lic.Class z
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 I�LSPEy,croR's
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES c� sr RS�R1 4r<
mess and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL y
Lic,or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE
�"L2() Jrf
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- 0 a
ness and Professions Code): No. PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the 2 - 6 6 2 .
structure is not intended or offered for sale (Section Y
7044, Business and Professions Code).
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY 1 G,n S—
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 PERMIT FEE
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I certify that I have read this application and state that the v
above information is correct.I agree to comply with all County ISSUANCE FEE �—s
ordinances and State laws relating to buil g construction, TOTAL FEE
and hereby author'ge re esentatives of t County to enter
e above-m ntio a proper for nspection purposes. SE REVERSE FOR EXPLANATORY LANGUAGE-7 -
Signat of Perml Date