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WORKERS'COMPENSATION DECLARATION I 75M444
CE 875(11-84) M ISCELLANEO•!-S PPLICATION
I hriTeby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES Y� BUILDAG AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,i r r•
a dertified copy thereof(Sec.3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FI LL.IN BUILDING
I ADDRESS
FICertified copy is hereby furnished. BUILDING /os-� G, O y �,�,C I LOCALITY
ADDRESS +'
FiCertified copy is filed with the county building inspection LOCALITY Y I NEAREST
department. �
CROSS ST.
Date Applicant NEAREST q DISTRICT NO. G_GUP TYPE CONST P ESSED BY
CROSS ST. /� �rj jJ(
CERTIFICATE OF EXEMPTION FROM WORKERS' ,. LEGAL '(
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP (CIRCLE)HIGHWAY STATE MAJOR SECOND LOCAL
I NO. OF SLOGS.
(This section need.not be completed if the work involved TRACT NOW ON LOT Use ZONE SPE CO I IONS
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 R. ���y1 C, O
so as to become subject to the Workers' Compensation Laws. r/ OCCUPANCY GROUP
I.
Date Applicant LU
NOTICE TO APPLICANT: If, after making this Certificate of CITY w �'�f NO. I OCCUPANT LOAD y
Exemption, you should .become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR , EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION❑ No Spec. Knowl. El
deemed revoked. ;OCCUPANCY INSPECTION Panic Devices E
LICENSED CONTRACTORS DECLARATION ,
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW t
9 (commencing with Section 7000) of Division 3 of the Busi- 7 No. of EXITS
ness and Professions Code,and my license is in full force and
effect. a e d ' 9 PARKING RKWO PROVIDED
I, SPACES
License Number Lie. Class LIMITED TIME USE
Contractor .Date hI DATE DATE
' I { PROM: TO:
0 I am exempt from the licensing requirements as I am a � - ' C .r/e.- I
licensed architect or a registered professional engineer SIZE of NO. OF ' I SSIGNATURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code).
EsENT USE OF BUILDING FINAL APPROVAL
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION _O- __ -
o. OF EXITING BUILDINGS
ON LOT A USE i
I hereby affirm that I am exempt from the Contractor's f ACCTog
License Law for the following reason (Section 7031.5, Busi t
ness and Professions Code): No. P KING ,:1317 227.7>_1
SPA CS PROVIDED
®I, as owner of the property, will do the work and the i 1 ITEMS
structure is not intended or offered for sale (Section
7044,Business and Professions Code). I
TOTAL T 1L 227®70
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
CNEt:I't 227e71.1
I hereby affirm that there is a construction lending agency �e�e-Ae' ` , HIE ,Q[1
for the performance of the work for which this permit•is :
issued(Sec. 3097,Civ.Q. I r�sc_ o
Lender's Name i (�
eD MAX. OC C. 1]I 1�1]-01301 5/12//35
Lender's Address £
p��Q 6% 1 AM V'-�C
I certify that I have read this application and state that the PERMIT FEE 90 O r711
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 FEE a x
upon th�entioned pro inspection purposes.I SEE REVERSE FOR EXPLANATORY LANGUAGE
.S' Z 7
Signature of Permittee Ifate