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WORKEPS'COMPENSATION DECLARATION 76M444 rVp p SC E L LA N EO U S APPLICATION
1. CE 875 (2-80)
1 here•,bv affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, Gr,a certificate of Workers'Compensation Insurance,or
a certitied copy thereof(Sec.3800,Lab.C.) I
Policy No. Company FOR APPLICANT TO FILL IN BUILDINDG
E] ADRESS
Certified copy is hereby furnished. BUILDING LOCALITY.
OADDRESS , �(������ L•
Certified copy is filed with the county building inspection NEAREST 01
department. LocwLITY w/� / L1 l� `-� CROSS ST.
Date Applicant CNEARESTROSS ST. Q /�'�YI Lf,, D ��S ,��LS DISTRICT NO. G OUP TYPE PROCESSED BY
/7 •D �j /J CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL O O�
DESCRIPTION LOT NO. BLOCK �.
COMPENSATION INSURANCE NOP (c RC E) STATE MAJOR SECOND LOCAL tl
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG, j tL
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 L 0Ae ry�
I U
so as to become subject to the Workers' Compensation Laws. MAIL a OCCUPANCY GROUP _ lL
ADDRESS v D ,� Y•fJ
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY p".,ij �f,4c., (- NOLO 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 C] No Spec. Knowl. Eldeemed revoked. Panic Devices ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT L--1 (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000)of Division 3 of the Busi-
El
ness and Professions Code, and my license is in full force and IVao-p av �n,Q� �j PARKING
effect. Q'` t�"L� ' REQ'D E:::= PROVID EO
License Number Lic.Class �� [7t d G SPACES I LIMITED TIME USE
Contractor Date GATE DATE _
❑ FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING L�KJ l••��/�
Lic.or Reg.No. Date
NO.OF EXISTING BUILDINGS
HOME OWNER-BUILDER DECLARATION ,
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
I, as owner of the property, will do the work and the \
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
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.C.).
Lender's Name PROPOSED MAX. OCG.
Lender's Address PERMIT FEE
I certify that 1 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, ITOTAL FEE
and hereby authorize representatives of this County to enter
upon the ve-men - ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Ignature of Permittee Date
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