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YORKERS'aCOMPENSATION DECLARATION 76M444
CE 875 (2-80) MISCELLANEOUS APPLICATION
I hereby a:{irm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
�iisure,'or a certificate of Workers'Compensation Insurance,or i
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company G g^ 1
FOR APPLICANT TO FILL IN BUILDINADDRESS 6J 2,6 s&Vf& /
❑ Certified copy is hereby furnished. D.R.SG Sfj�6 7G,�O,�.LE �` LOCALITY
1:1
ADDRESS QOO� .
Certified copy is filed with the county building inspection
- • NEAREST
department. LOCALITY //_A' J CROSS ST.
Date Applicant NEAREST ,/ DIST�'LC ��qq SOUP TYPE PR SED BY
CROSS ST. S �uN S !� �/ CONST. V
CERTiFiCATE'OF EXEMPTION FROM WORKERS' LEGAL
1 D V
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP qiS HIGHWAY }
NO. F BLDGS. O
NO. (JU (CIRCLE) STATE MAJOR SECOND OCAL d
(This section need not be completed if the work involved TRACT NOW OON LOT USE ZONE S ECIAL CONDITIONS V
by the permit is for one hundred dollars (5100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this O
permit is issued, 1 shall not employ any person in any manner x OWNER ® U
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP W
\� �, a
X ADDRESS to
Date Applicant
Ti
NOTICE TO APPLICANT: If, after making this Certificate of X CITY noL �"��� 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 NOS Spec. KnOWi. ❑
deemed revoked. 1:1P
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS ❑
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect.
SPACES REQ'D D PROVIDED O
License Number Lic.Class LIMITED TIME USE
Contractor Date DATE DATE
❑ FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OFNO. OF rINSPECTOR'S
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES �.�.,//►1 /� SIJrNATURE
iness and Professions Code). PRESENT USE OF BUILDING ��� FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND USE ' A
I hereby affirm that I am exempt from the Contractor's 0 1 610 1# 0 0 0 0 883,0
A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO.PARKING 0 f1 0 q 0 0 0 2
SPACES PROVIDED 3 o 6 85
❑ 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).
RO POSED USE OF BUILDING t.
v
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. OCC.
Lender's Address 6;;RMIT FEE
I certify that I 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, TOTAL FEE
and hereby authorize representatives of this County to enter
n the abo a-menti ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
tigrAture olyPermittee Date