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WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself CE 875(11-84)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 BUILDIG .S !^
ADDRESNS J
FiCertified copy is hereby furnished. BUILDING —/ LOCALITY
ADDRESS •--..yyyyy.. /�
Certified copy is filed with the county building inspection 1 / /T NEAREST
LOCALITY
department. sr C / CROSS ST. Lim
Date Applicant NEAREST DISTRICT G U TYPE PROCES ED BY
CROSS ST. � ✓(7l`J/ CONST' /
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �-j v
COMPENSATION INSURANCE DESCRIPTION LOT NO. ✓ BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SEC LOCAL
NO. OF BLDGS.
(This Section need not be completed if the work involved TRACT 1361-,3 NOW ON LOT USE ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usIS OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG.
D_
permit is issued, I shall not employ any person in any manner OWNER o
:.7
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP
ADDRESS %�Owod& O
Date Applicant 'f LO
L
NOTICE TO APPLICANT: If, after making this Certificate of CITY v /L�p NO
� yj 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 ❑ No Spec. Knowl. EJ
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 andy�p�/J
effect. 714��� PAARKING
SPCES REQ'D PROVIDED
License Number Lic. Class �l /p �� LIMITED TIME USE
Contractor Date •� DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INS PE CTon's
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE
iness and Professions Code).
FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's 0 9 7.5 A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
# O O O D 3 O
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section I o 0 8 Q 5 0
7044,Business and Professions Code).
PROPOSED USE OF BUILDING o 0 0 $Q 5 0 v
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 1 G24-88
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address !,
PERMIT FEE 70-6/01
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize represe of this County to enter TOTAL FEE S
upon the above entioned qf6perty for i tion purposes. `
�C SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date