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WORKERS'COMPENSATION DECLARATION ce B754tt1 84) MISCELLANEOUS APPLICATION
I hereby affirm that 1 have a certificate of consent tself 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. Com"pany GfGNA tAoRgaa
y wl-Rch93338'/p�J FOR APPLICANT TO FILL IN
Certified copy is hereby furnished. V" X BUILDING ADDRESS r/ RQ ALITY
Rese�e�
Cert d y is filed with a count uil Ing inspection LOCALITY C� wr+EOT
OSS ST.
Date Applicant NEAREST DISTRICT NO,
G OUP TYPE E39fiD BY
CROSS ST. . /� G CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C/a
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP ' HIGHWAY STATE MAJOR SECOND LOCAL
No. I (CIRCLE)
NO.OF SLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE LONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner "1 owP-- of building &Mc- SNI/arMEAhr
so as to become subject to the Workers'Compensation Laws..r--
MAIL 3,13 S. �'LO A ffsSoc. OCCUPANCY GROUP
ADDRESS ,r3S /QQOSeA,,1 /J IIO. V
Date Applicant '''
NOTICE TO APPLICANT: If,after making this Certificate of CITY Tem NO. 8/$ � ,?_ SG OCCUPANT LOAD vi
Exemption, you should become subject to the Workers' ' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth- 1
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 PERMIT❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code,and my license is in full force at -�
effect. 49' Na--
me of business Sc RmsleR,s PARKING
/�� SPACES REO'D PROVIDED
License Number Lic.Class I $.9 e v 1w Rcvisi1 R5 LIMITED TIME UJ?U r E`�-
Contractor DateI -
1 Owre OwrE QI
FROSRI TO:
I am exempt from the licensing requirements as I am a i IN9PE TOR.
licensed architect or a registered
professional engineer slzE OF No.OF %�i LLTU
gl p SIGN�►TURE• ••!"•
acting in my professional capacity (Section 7051, Bur I EXISTING BLDG. STORIES
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date i
HOME OWNER-BUILDER DECLARATION I NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that 1 ant exempt from the Contractor's I
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No.PARKING
I
1, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sea 3097,Civ.C.).
Lender's Name
PROPOSED MAX.OCC.
Lender's Address _
PERMIT FEE 25.00
Lcertify that 1 have read this application and state that the
ove information is correct.1 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 25.00
upon the above-mentioned property for inspection purposes:
I <— ?SEE REVERSE FOR EXPLANATORY LANGUAGE