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WORKERS'COMPENSATION DECLARATION 176M444
-� CE 875(11-84) M ISCELLANEOUS PPLICATION
I hereby affirm that I have a certificate of co*sent to selfCOUNTY OF LU ''}�;1VGELES B 'I ILDING AND SAFETY DIVISION ;1
insure, or.a certificate of Workers'Compensation Insurance,.or
a certified copy thereof(Sec.3800,Lab.Q.
Policy No. CompanyFOR'APPLICANT TO FILL IN ADDbIS
ADDRESS
Certified copy is hereby furnished. BU ILDIND I . LOC;LITY ��1 I
XX ADDRESS I/ IS1 VfV
E Certified copy is filed with the county building inspection LOCALITY
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department. JM 1 I c:Aif ST.
Date Applicant NEAREST D19YRIC No I.;Fp CONST. P EBBED BY
CR09S ST. ',� •�• ITYPIC
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L' le�ipl
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP 5 MICMWAr
OF BLDGS. NO- ICIRCLE) STATIC MAJOR SECOND LOCAL
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(This section need not be completed if the work involved TRACT NOW ON LOT USE ICONIC SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) use of
BLDG.
SIZE OF LOT BXISTING `
I certify that in the performance of the work for which this ( ci
permit is issued, I shall not employ any person in any mann§EXl. OWNICR of building �OCCUPANCY GROUP
01-
so as to become subject to the Workers Compensation Laws. ( MAIL a 1 ,/dJ� c,
'ADORESS
Date Applicant 41
TEL'
NOTICE TO APPLICANT: If,after making this Certificate of elrr e d o. tl - �- 0?3
OCCUPANT LOAD
Exemption, you §hould 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❑ No Spec. Knowl.
deemed revoked. I
LICENSED CONTRACTORS DECLARATION -OCCUPANCY INSPECTION 11Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT[] ( MLIST ITICS 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 anX
effect. Name of business PARKING REO'D 1 1 PROVIDED
SPAf:ES IL--_-JJ 1�
•
License Number -- I.ic.Class LIMITED TIME USE
t
Contractor Date ( DATE DATE
ElI am exempt from the licensing requirements as I am a 1
licensed architect or a registered professional engineer SIZE OF cam}, Nom.OF FRO*: To. INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLD.. abt. L7 VV � STORIES �e SIGNATURE
iness and Professions Code). V FINIAL APPROVAL
Lic.or Reg.No. —Date PRESENT USE OF BUILDING Ip .v
I
110ME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS
ON LOT AND UBE
1•hereby affirm that I ant exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): I NO. PARKING !
I; as owner of the property, will do the work and the I SPACES PROVIDED
structure is not intended or offered for sale (Section i
'7044,Business and Professions Code).
.I
( CONSTRUCTION LENDING AGENCY I
1 hereby affirm that there is a' PROPOSED USE OP BUILDING
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 '�' r+�
PERMIT FEE I I"`` Ill
1 certify that 1 have read this application and state that the + 71111
above information is correct.I agree to comply with all County I ISSUANCE FEE
ordinances and State"laws relating to building construction,
and hereby authorize'representatives of this County to enter TOTAL.FEE 25.00 r.
upon the above-mentioned property for inspection purposes. ,
7 - I SEE REVERSE FOR EXPLANATORY LANGUAGE
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