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W,I)R+I:ER'$'COMPENSATION DECLARATION CE 875(1 1-84) MISCELLANEOUS A P P L I C A T I O N
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. Company I FOR APPLICANT TO FILL IN ABUILDING
DDRESS I' �N(D �V
ElCertified copy is hereby furnished. BUILDING // �r �: /�rT•
ADDRESS (f /�+�"/,p 7?V. ,VU6 LOCALITY
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
department. jE/tf/�aE CROSS ST. w
Date Applicant NEAREST DISTRICT NP. 9-3 TYPEg�l RD
POCESSEBY
CROSS ST. �/'��ry CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALNS
COMPENSATION INSURANCE DESCRIPTION LOT NO. 1O� BLOCK MAP HIGHWAY
NO. OF BLDGS.
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
t
(This section need not be completed if the work involved TRACT Alk NOW ON LOT USEZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) `
SIZE OF LOT�✓ � EX ST NG BLDG.
Us
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`1jA,4,?/.IH CCrPila�/.�E ATGiEc� S�
so as to ecome subject to the W rkers' Compensation Laws. MAIL OCCUPANCY GROUP•
rL / ///� //�1 / 0
° ADDRE53.7 Jj�(f/ /L L,A/�I� /-°✓E+ti/LII�' . ' •'. � �
Date Applicant) .�� � -
NOTICE TO APPLICANT: If, after making this Certificate of CITY 14 f: je 6,r NOL OCCUPANT LOAD N
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR 'EXIT HARDWARE: _
with comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑
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: i NO. OF EXITS
ness and Professions Code,and my license is in full force and . /
effect. CY PARKING REWD PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a FROM: TO!
licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S
acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING �&�
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS } 0 0 0 0 3 D
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's 1 - 80.50
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING8/V,� 5 0 5 x
I, as owner of the property, will do fire work and the SPACES PROVIDED D D O_
structure is not intended or offered for We (Section `'0 7 21A—8 8
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(Sec.3097,Civ.Q.
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 Rlif 1Q0
upo the above-mentioned property for inspectionpurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date