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WORKERS'COMPENSATION DECLARATION CE 874(1 1-84) 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.Q.
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. uILDING l �r' LO CALITY�
ADDRESS (r V
departiment Py is filed with the county building inspection LOCALITY j u C! CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE CESSED BY
CROSS ST. u y`D� 3 CONST,..,,
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ) -
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND L AL
No.�j6D' _(py (CIRCL C)
NO. OF BLOGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF //��
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. C ,
permit is issued,I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. aADDR
/ OCCUPANCY GROUP Ek�] o
ESSv�I/ az • 6 F SDate Applicant OCCUPANT LOADNOTICE TO APPLICANT: If, after making this Certificate of �'L p No. r„
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: z
Compensation provisions of the Labor Code,you must forth
with comply with such provisions Or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Know[.
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
El
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
effect. PARKING
SPACES REO'D D PROVIDED D
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
ElI 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 ATURE
iness and Professions Code). , I C FINAL APPROVAL
PRESENT USE OF BUILDING )/
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, Busi-
ness and Professions Code): NO. PARKING
0 I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING ;26060Af
I hereby affirm that there is a construction lending agency # o o o 0 8 8
for the performance of the work for which this permit is ¢ $G E1 6 Tn
issued(Sec. 3097,Civ.Q.
Lender's Name [��!
tF
PROPOSED MAX. OCC.
Lender's Address r Z
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, NF
and hereby authorize representatives of this County to enter TOTAL FEE
upZi, o -m tioned rope y for inspection purposes.
E REVERSE FOR EXPLANATORY LANGUAGE
SE
Sig of Permittee Da e