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�WORIiL'TCONUPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I lure, o affirm that I have a certificate of consent tc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. CompanyBUILDING 'I
FOR APPLICANT TO FILL IN ADDRESS CiI
Certified copy is hereby furnished. BUILDING LOCALITY Y =
ADDRESS Q 1„�.f•�?! I,.J_ �/
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. I �— CROSS ST.
Date Applicant NEAREST ,� DISTRICT yyO. G OU TYPE MSSED BY
ROSS ST. � �, CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. 3 BLOCK MAP HIGHWAY STATE MAJOR SE ND LOCAL
F BLDG S'
NO. (CIRCLE)
(This section need not be completed if the work involved TRACT NOW ON LOT US ZO11a SPECIAL CONDITIONS
i5 01 o NO. O
by the permit is for one hundred dollars ($100) or less.) (-)X J usE OF
SIZE OF LOT EXISTING BLDG. '` a
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 ='
so as to become subject to the Workers' Compensation Laws. MAIL o
OCCUPANCY GROUP
ADDRESS L 11/� / V
Date Applicant ul
NOTICE TO APPLICANT: If,after making this Certificate of CITY y PA TNEOL-g-IS4 7/ �p OCCUPANT LOAD
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.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑/ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PER (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 pN
effect. E ��I7'h DDD,J
Lt/ /t 4�r� l7/ PARKING SPACES REq D PROVIDED
License Number Lic. Class O^/ G orSPACES
TIME USE
Contractor Date teE• DATE DATE
❑ I am exempt from the licensing requirements as I am a
PROM: To: INSPECTOR'S
licensed architect or a registered professional engineer SIZE OF No. of
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code). FINAL APPROVAL `�
PRESENT USE OF BUILDING c.
Lic.or Reg.No. Date ,
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No. PARKING
SPACES PROVIDED
El I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ;271 O A
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING # 0 0 0 03.0
I hereby affirm that there is a construction lending agency I ° ° 8 Q 5 0
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name ° ° ° 8 Q 5 0 c=J
PROPOSED MAX. OCC.
Lender's Address 0 603-87
PERMIT FEE
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 representatives of this County to enter TOTAL FEE .\�
upon the above-mentioned property for ins ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
S' ature of Permittee Date