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WORKERS'COMPENSATION DECLARATION CE 876(1 1-84) M l SC E L-LA N E O U S APPLICATION
I hereby affirm that I have a certificate of consent tself ,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.Q. '
Policy'No. Company FOR APPLICANT TO FILL IN BUILDING /��_7_
ADDRESS 43� /� GC//f
Ej Certified copy is hereby furnished. BUILDING O
ADORE & LOCALITY
Certified copy is filed with the county building inspection LOCALITY f� NEAREST
department. ( CROSS ST.
NEAREST r DISTRICT NO. G OUP TYPE PROCESSED HY
Date Applicant CROSS ST. f�4• P _3 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
X
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. o
permit is issued,I shall not employ any person in any manner OWNER 14MSI
so as to become subject to the Workers' Compensation Laws.
MAIL •OCCUPANCY GROUP [Zil
o
ADDRESS C_1 V
Date Applicant TEL
NOTICE TO APPLICANT: If,after making this Certificate of CITY No. s j OCCUPANT LOAD z
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 OI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ ' Nb Spec. Knowl. 0
deemed revoked.
LICENSED CONTRACTORS DECLARATION occuPANcr INSPECTION Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (M&T ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi. No, of EXITS
nese .and Professions Code,and my license is in full force anA
d ^
I-� PRKING SPACES RSQ'D PROVIDED
License Number Lic. Class
J( Yl P �
• LIMITED TIME USE
Contractor Date ® D D Y DATE DATE
:r
D I am exempt from the licensing requirements as I am a FROM TO:
licensed architect or a registered professional engineer SIZE OF /9 NO. OF SIGNATURE
INSPECTOR'S
acting in my professional capacity (Section 7051, Bus-• EXISTING BLDG. /Ii STORIES
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date Off�s
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
p.r. E
I hereby affirm that I am exempt from the Contractor's A%L °F
License Law for the following reason (Section 7031.5, Busi- . ;i j
0• 274° =1
ness and Professions Code): No. PARKING
SPACES PROVIDED b
I, as owner of the property, will do the work and the " I ITEMS
structure is not intended or offered for sale (Section
7044,Business and Professions Code). TOTAL 234 -45
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY CH CK ? 4.°4}
I hereby affirm that there is a construction lending agency CHANGE °1111
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name I_ - /94
PROPOSED MAX. OCC. �,
Lender's Address
I certify that I have read this application and state that the PERMIT FEE 4,'�'69 J, RM12'-13
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 TOTAL FEE0.
upon the above- ent' p pert for i spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature f Permitte ate