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1 )ZI;I'RS'r0`IPENSATION DECLARATION
CE 875(11-84) .MISCELLANEOUS APPLICATION
CE 875
I herebyaffirm !hut I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure;or a cerfificate of Wolters'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS ��dZ
Certified copy is hereby furnished. BUILDING
ADDRESS `� � 11VAR
LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST Av
department. CROSS ST.
Date Applicant NEAREST ` �� DISTRICT NO. GROUP CONS ITYPE P ESSED BY
GROSS ST. ' �Q' J
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATMAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLOGS.
(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
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this /&,I t)— �y o
permit is issued,I shall not employ any person in any manner OWNER ,—
so as to become subject to the Workers' Compensation Laws. MAIL �L OCCUPANCY GROUP zE3
ADDRESS gn0 ,& o A 0A1 EZal
U
Date Applicant
uJ
NOTICE TO APPLICANT: If, after making this Certificate of CITY I,C 4 ITvoL.' (0 � OCCUPANT LOAD
r
Exemption, you should become subject to the Workers' APPIfICATION 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 No Spec. Knowl.
❑
deemed revoked. ❑ ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000)of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING REQ'D PROVIDED
SPACES
License Number Lic. Class �— v �"s� LIMITED TIME USE
Contractor Date DATE DATE
❑ I am exempt from the licensing requirements as I am a fool
FROM:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPE CTORE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL ���ggg
PRESENT SE OF BUILDING I� T
Lic.or Reg.No. Date � r JJ
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS `'10
ON LOT AND USE KU
y
I hereby affirm that I am exempt from the Contractor's �l�t�t=3
License Law for the following reason (Section 7031.5, Busi- 3303 ',}. 8=o5
ness and Professions Code): NO. PARKING —
SPACES PROVIDED I ¢-ii}
I, as owner of the property, will do the work and the _ #'T^ `
structure is not intended or offered for sale (Section
7044,Business and Professions Code). TOTAL
IT�� ��� � d--'3,!5
CONSTRUCTION LENDING AGENCY PROPOS USE OF BUILDING 2 '
_ `
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.Q.
Lender's Name (}000-001 i} 6/3-0 191:5
PROPOSED MAX. OCC,
Lender's Address -) i 7 y
PERMIT FEE � C �2'"2'� ' ��� �_,.
I certify that I have read this application and state that the G
above information is correct.I agree to comply with all County ISSUANCE FEEa a
or d' yes and State ws relating to building construction, „
and h ebyauthoriz r resentatives of this County to enter TOTAL FEES
upo to above men ' d property fo inspection purposes.
EE REVERSE FOR EXPLANATORY LANGUAGE
S—
igna Gre ermit ee Date