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WORKLRS COMPENSATION DECLARATION 76M"4 M ISCELLANEOUS APPLICATION
• CE 876 (11 84)
rl hereby a Certirin that I have a scertLfu,ite'Compen of consent to reef COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
Insure, or a cerldlcate of Workeri Compensation Insurance,or
a ceridkd copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUoow tiI R ISO
we
Certified copy is hereby furnished eU"" - - Lo c. Y
uT
3(x woow[r r/1_
F Certt ied Cou filed with the count budding
PY Y frig inspection LOCALITY NEAREST
department XX ewoSS ET
Date Applicant NEAREST e • ^'� L otSTR No awo TYPE ESSED BY
CFO LEG
Ste.`�1 ' O OONET
CERTIFICATE OF EXEMPTION FROM WORKERS' LEG
COMPENSATION INSURANCE DESCRIPTION LOT NO - ewcw N^P jID"w^j
NO or 151.005SrwrE Mwaow S[conD LOCAL
woc,w u.
N
(This section treed not be completed if the work involved TRACT nor ON LOT us[:o TIE SPEeu
D L CONDITIONS
by the permit is for one hundred do0ars (5100) or len.)) USE or
[ .
1 certify that m the performm r ance of the work for which this SIZE or LOT .. vYema BLDG n
permit Issued, I shall not employ any petson any manneo—w of buildin
so as to become subject to the Workers' Compensation laws MAIL - Me S OCCUPANCY GROUP
ADDRESS �1
Date Applicant
NOTICE TO APPLICANT If, after making this Certificate of etrr .PYA L Z53 OCCUPANT LOAD N
Fxemptwn, you should become subject to the Workers ,T —
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE
with Comply with such provisions or this permit dull bec^
deemed revoked TR wIL[w LIS[ ❑ G[oLoor INSPECTION ❑ NO VytK KrIOWI
I ICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Pante Devices
1 hereby affirm that I am licensed under provisionsof Chapter SAr ETY PERMIT ❑ (LIST ITEMS BELOW)
9 (Commencing with Section 7000) of Division 3 of the Busr No or EXITS
Ness and Professions Code,and my license is in full force ta a
effect Name of busines PARKING
�1 `` SPA
Cgs
w[a o PwovaD[o
License Number ss
Lic Clan G I�•
LIMITED TIME USE
contractor Dat AT. DAT.
..DM
I am
en exempt from the licensing requirements as 1 am a INSPE crow A
licensed architect or o registered professional engineer EXISTING or No or SIGNATURE
acting m my professional capacity (Section 7051, Bus- ultnna BLoo 0 SroeIES `
mess and Professions Code) FINAL APPROVAL �.��
I is or Reg No Date
PRESENT LIS[ or BUILDING NAL
IIOMI OWNFR BUILDER DFCI ARATION No or EAISTINO BUILDINGS O I/AA
ON
LOT AND USE f/I hereby affvm that 1 am exempt from the Contractor's
I inns I aw for the fUllow mg reason (SCLllon 7031 5, Busy
Bess and Professions Code) NO PARKING
1, as owner of (lie property, will do the work and the SPACES PROVIDED
structure u not intended or offered for ale (Section
7044,Business and Professions Code)
CONST RUCI ION LENDING AGENCY PROPOSED USE or BUILDING
I hereb) affirm that there is a construction lending agency
for the performance of the work for which this permit is
Issued(Sec 3097 Cry C
Lender s Name
PROPOSED MAX OCC
I ender s Address r=
PERMIT FEE ��
1 certify that I have read this application and state that the T
above Information Is correct I agree to Comply with all County ISSUANCE FEE y
dUances and tate laws relating to building Construction, 1
hereby a rite representatives of this County to enter TOTAL FEE 25 .00 r
III a en o perly for mspeLtion urp s. -
\ 1 Xg IF 7 SEE REVERSE FOR EXPLANATORY LANGUAGE y �
1 ivn i1we of Pernnttrr arc I