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WqI KERS-COMPENSATION DECLARATION 7s �a �. I ,
CE ,5,,,_aa, _ 'M IS'�ELLANEOUS�APPL{: AT'10'N
I hyreby afiam that I have a certificate of consent to self ? COUNTY OF"E(3S_A_ANGELES BUILDING::SND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or i
a certified copy thereof(Sec.3800,Lab.C.). 1
Policy No. Company FOR APPLICANT TO F'I LL IN BUILDING sC�-3`l L y)
ADDRESS l 4) /j• y �n![/ 41)6,
MCertified copy is hereby furnished. BU ADDRESS 5530 N a e LOCALITY C,
DCertified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT N Gq�pU TYPE / PROC BD B
aRoss ST. beeen D 'n & Bogue 5U K� CONST•, V
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NOP' HIGR CLS' STATE MAJOR SECO LOCAL
NO. OF BLDG S.
(This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG, res.
I certify that in the performance of the work for which this o
permit is issued,I shall not employ any person in any manner OWNER Habib, Fawzy & Sonja s'
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP•- 0
Date Applicant ADDRESS same as above �` W
TEL. 444-3633 OCCUPANT LOAD
NOTICE TO APPLICANT: If,after making this Certificate of clrr No.
Exemption, you should become subject•to the Workers' _
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION El
revoked. El ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION [ Panic Devices
EJ
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi NO. OF EXITS
ness and Professions Code,and my license is in full force and l � KUO 8�,o d
effe6t. PARKING REQ'D PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor DateDATE DATE
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF No. of PROM: To: INSPECTOR'S
acting in my professional capacity (Section 7051, Bui- EXISTING BLDG. STORIES 2 SIG ATURE
iness and Professions Code).
�,[.'"
PRESENT USE OR BUILDING FINAL APPROVAL 1 01
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE '
I'hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Bu$i ;2 6 5.1.2 A
ness and Professions Code): NO. PARKING #.0'0 0-'0.3.0
.SPACES PROVIDED
M I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section 1'b.6'8'Q;'.5 0
7044,Business and Professions Code). ` _
DaB 0.5-O U
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 0,213-87 '
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 aurite re ntativ s this County to enter TOTAL FEE
upon the abo . 1 1 10 ropert r uspec on purposes.
`r- SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re of Permittee Date