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WORKE%tS'COb3?ENSATION DECLARATION +CE 875(2-80) W SC E L LA N E®U S APPLICATION
I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BU
insure, or a certificate of Workers'
BUILDING AND SAFETY DIVISION
Compensation Insurance,or �
a certified copy thereof(Sec. 3800,Lab.C.)
Policy.No. Company FOR APPLICANT TO FILL IN BUILDINGTT
ADDRESS
❑ Certified copy is hereby furnished. ;BUILDING. LOCALITY
El Certified copy is filed with the county.building inspection ADDRESS
�"�T�? NEAREST
department. LOCALITYL-14 I • A CROS- ST.
Date Applicant NEAREST ' DISTRICT NO'. GRQQQ¢����UUU11�iy TYPE PROCE BY
CROSS ST. O CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' I LEGAL J
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP G HIGHWAY }
NO. Q (CIRCLE) STATE MAJOR SECO LOCAL IL
(This section need not be completed if the WOIk InVO1VedTRACT NOW ON LOT NO. OF 5. USE ZONE SPECIAL CONDITIONS V
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. '� W
I certify that in the performance of the work for which this ll �n! O
permit is issued, I shall not employ any person in any manner OWNER S !�/v UV
so as to become subject to the Workers' Compensation Laws. MAIL 'OCCUPANCY GROUP ff-31 W
ADDRESS
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY OCCUPANT LOAD., z
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 0 GEOLOGY INSPECTION C1 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 I--1 (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi01 F
-
ness and Professions Code, and my license-is in full force and Aoejo
PARKING REWD = PROVIDED
SPACES
License Number Lic.Class 4V4 n4d 31�? RMI7 LIMITED TIME USE
Contractor Date D ATE DAT E
FROM: ro:
F1I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting in my. professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES IGNATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL l�✓
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
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section 94 7 3,3 A
7044,Business and Professions Code).
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency ,1 o ID 8 a 5 0
for the performance. of the work for which this permit is
issued(Sec. 3097,Civ.C.). I x
Lender's Name o 0 0 $'a 5 0 c�
PROPOSED MAX. OCC.
Lender's AddressPERMIT FEE VD' .Ogg 0..5 2 9-8 6
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 d
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 1 3
�ntabove-mentioned operty �prinspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� � 9-0
Signature of Permittee Date