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WORKERS'COMPENSATION•DECLARATION !, 7G 875(2-80) M �S C E Lm 1�I LA E O U S APP 6��C d'�A T I®II�!
I hereby affirm I have certificate of consent to'self ;. COUNTY OF LOS ANGELES :BUILDING AND SAFETY DIVISION
insure, or-a I�rtifscaticate of Workers'
rs'Compensation Insurance,.or 4
a certified copy thereof(Sec.3800,Lab.'C.) ;, f
Policy No. CompanyBUILDING
F.OR'APPLICANTTO FILL IN Ar�G RE Sa i--.
Certified copy is hereby furnished. BUILDING LOCALITY
DF
jl ADRESS
M Certified copy is filed with the county building inspection NEAREST
department. LocwLlrY - cdoss ST.
Date Applicant IQEAREST f� DIST.RICT NO G "UP YPE PROC SSED BY
CROSS ST. �Lt 0 /iC-6vtJ�� /1� " ,/) CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS.' i LEGAL - -7
C.OMP$NSATION INSURANCE DESCRIPTION LOT NO': BLOCK MAlp HIGHyypy'" ,
No. (c IRGLe) STATE MAJOR SECOND LOCAL }
(This section need not be completed if the work involved I TRACT NOW ON LOT BLOGs. C
USE ZONE SP ECIAL-CONDITIONS O
by the. permit is for one hundred dollars ($100) or less.f '. USE:OF U
E '
I certify that in the performance of the work for which this: I SIZE OF LOT XISTING BLDG.
permit is issued, I shall not employ any person in any manner NER Ar
r O
so as to become subject to the Workers' Compensation Laws. I OCCUPANCY GROUP
AM
31, ADDRESS �Q7 LU
Date Applicant OO/SS`
TEL. uc-7
NOTICE TO APPLICANT: If, after making this Certificate of. clmY No. p��' 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 '
deemed revoked. TRAILER USE GEOLOGY INSPECTION❑, I' NO Sped. Knowl.
OCCUPANCY INSPECTION Panic DeVICBS. ❑'. '
LICENSED CONTRACTORS DECLARATION
I hereby affirm that Tam licensed under'provisions of Chapter.. j SAFETY'PERMIT Q (LIST ITEMS BELOW) 'N O. OF EXITS
9 (commencing with Section 7000)of Division 3 of the BOA;
El
neif, and Professions Code,`and my license is in full force and PARKING.
effect. SPACESREQ'D PROVIDED
. - ' ' '
License Number - Lis.Class
LIMITED TIME USE..
Contractor 'Date ” ( DATE GATE
aFROOM: ' TO: '
I am exempt from the licensing requirements as I am a:'
licensed architect or a registered professional engineer SIZE OF NO. OF4 INSPECTOR'S
acting in my•professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 'SIGNATURE
iriess and'Professions Code); I. RP�EsE1VT USE OF BUILDING VadoN F1iIV'AL APPROVAL
Lic.or Reg.No.., Date
HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS r ,
ON LOT AND USE
I hereby affirm that. 1' am exempt from the Contractor's
License Law for the following reason (Section 7031.5,,,.Busi '
NO..'PARKING C,
)• .
ness and Professions Code): ' SPACES PROVIDED '
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). P.I.P.ED USE OF BUILDING ( ✓
S /1 1202=a2 '
CONSTRUCTION LENDING AGENCY ` J NG` Pl E7
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 PERMIT 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,
TSI
and.hereby authorize representatives of this County to enter TOTAL FEE,.;?5'
upon the above-mentioned 'property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature.of Permittee Date