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WORKERS'COMPENSATION DECLARATION CE 875
(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a 'certificate of consent to 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.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS Q
Certified copy is hereby furnished. BUILDING _
ADDRESS 1V LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST '
department. CROSS ST.
Date Applicant NEAREST - DISTRICT O, Ogpj TYPE PRO�SSCDBCYALGROSS ST. _ f7CONSTaCERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL / I VVIVJCOMPENSATION INSURANCE DESCRIPTION LOT NO. ! O BLOCK MAP HIGHWAY(CIRCLe) STATE MAJORS
`/. NO. OF BLDGS.
(This section need not be completed if the work involved TRACT16 u 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. d
I certify that in the performance of the work for which this
0
permit is issued, I shall not employ any person in any manner OWNER . S 5 y
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP . o
Date Applicant ADDRESS ���� N. R >° 8
W
NOTICE TO APPLICANT: If,after making this Certificate of CITY '� n 0No� y 4/�—�O OCCUPANT LOAD Z
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 USEGEOLOGY INSPECTION Eldeemed revoked. ❑ ❑ No Spec. Knowl.
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 I
effect. 4J C� �} PARKING SPACES REq'D =
PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DAYS
FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO.OF I SIGECTURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code).
FINAL APPROVAL
Lic.or Reg.No. Date PRESENT USE OF BUILDING ((��
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS r 8 4 Q 0 A
ON LOT AND USE `
1 hereby affirm that I am exempt from the Contractor's o 0 0 o v Q
License Law for the following reason (Section 7031.5, Busi- I o o 8 Q 5 0
ness and Professions Code): NO. PARKING
SPACES PROVIDED O O O 1; 0 C =
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). 11.20-37
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(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
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 ti
upon the above-mentioned pro rty for inspection pu poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
AZI
Signat r of Permittee Date