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"WORKERS'.COMPENSATION DECLARATION 75M444 M I SC E L LA N E O U S APPLICATION
CE 875(11-84)
I hvl�by' litfrm that I have a certificate of consent to self COUNTY OF LOS ANGELES /BU DING AND SAFETY DIVISION
insured or a certificate of Workers Compensation Insurance,or '
a certified copy thereof(Sec.3800,Lab.Q. 1
PolicyNG
No. Company ADDRESS sy
FOR APPLICANT TO FILL IN woDREss
Certified copy is hereby furnished. [LOCALITY
DING %� &
• RESS �E�' 8� LOCALITY
Certified copy is filed with the county building inspection NEAREST
department. rGiM P ceoss ST.
Date Applicant NEAREST I �� ��J I DISTRICT NO. GROUP TYPE PRO ,,��55E��D BY
I CROSS ST. l v` CON
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTI ON' LOT NO. HLO CK MAP HIGHWAY STATE MAJOR SEGO D LOCAL
SLOGS. NO. (CIRCLE)
F
(This section need not be completed if the work involved TRACTJyo ` NOW ON LOT U36 ZONE1 .
SPACIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) I USE OF
SIZE OF LOT EXISTING BLDG. d
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner OWNER 1\`A_ V' r-0106& y
so as to become subject to the Workers'Compensation Laws. MAIL
Date Applicant //
OCCUPANT LOAD y
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 UsEGEOLOGY INSPECTION ❑
❑ El No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
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-
ness
NO. OF EXITS
and Professions Code,and my license is in full force and r6coa-lirA� G �r✓�S �� PARKING
effect. SPACES REQ'D PROVIDED
License Number Lic. Class ID
LIMITED TIME USE
Contractor Date DATE DATE
FROM: To: MI INSPECTOR'S
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO.OF _.+
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES - _ SIG R6
iness and Professions Code). FINAL APPROVAL H-A :iJ '1�
Lic.or Reg:No. Date PRESENT USE OF BUILDING ' -t5
.f i{ f—
S ! J G-e nuc, e�� e
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1 IT`M'-
ON LOT AND USE
}�
I'hereby affirm that I am exempt from the Contractor's
T i�TAL y,�IX-4--.45
License Law for the following reason (Section 7031.5, Busi CHrr-
4.45
ness and Professions Code): NO..PARKING
ES PROVIDED 'S
I, as owner of the property, will do the work and the SPACCHANGE .013
structure is not intended or offered for sale (Section 1
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOS usE of BUILDING tttt�,l[1–(itt(;i j 0,.4 `1?t
I hereby affirm that there is a construction lending agency �� titles i ; y
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name
Lender's Address
PROPOSED MAX. OCC.
�D ' ,
I certify that I have read this application and state that the PERMIT FEE 9V
above information is correct.I agree to comply with all County ISSUANCE FEE
oro' ces and State laws relating to building construction,
n eby authorize representatives of th'� County to enter TOTAL FEE
u n e lov
Toned property for i p ctionp ' os s.
1� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee P'( ate
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