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yVORKIwRS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm 9hat I have a certificate of consent to self i 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. BUILDING g� E D6
A'DOR ESSY114 LOCALITY
Certified copy is filed with the county building inspection LOCALITY //1�1 C NEAREST
department. 2LF- 1 CROSS ST.
Date Applicant NEAREST DISTRICT N UP TYPE P O ED
CROSS ST. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ' V
COMPENSATION INSURANCE IDESCRIPTION I LOT NO. BLOCK M&P11ICN
NO. (CIRCLE)
STATE M JOR ND LOCAL
I
NO. OF SLOGS.
(This section need not be completed if the work involved TRACT 97,2 -15" NOW ON LOT , USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) i , USE OF
SIZE OF LOT40 k 3 0 EXISTING BLDG. O.
/ }
I certify that in the performance of the work for which this I o
permit is issued,I shall not employ any person in any manner OWNER VEWAJI A Al f J'LL
so as to become subject to the Workers' Compensation Laws. MAIL f OCCUPANCY GROUP o
ADDRESS PJ �_
Date Applicant
TEL'
NOTICE TO APPLICANT: If, after making this Certificate of cITl�� NO. OCCUPANT LOAD rr
Exemption, you should become subject to the Workers' APPLIC ION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be TRAILER USE E] GEOLOGY INSPECTION I No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I 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 NO. OF EXITS
ness and Professions Code,and my license is in full force and /�
effect. �. C O C. iPARKING HEWS) PROVIDED
SPACES.
License Number Lic. Class I j3A I LIMITED TIME USE
Contractor Date 0 fl DATE DATE
I
F1 I am exempt from the licensing requirements as I am a FROM! TOI
licensed architect or a registered professional engineer SIZE OF NO. OF ` SPECTOR
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES I ni IG ATURE
iness and Professions Code). N FINAL APPROVAL V
BUILDING V
Lic.or Reg.No. Date PRESENT USE OF {
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's ACC_.q
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): 1V0. PARKING I
I, as owner of the property, will do the work and the iPACES PROVIDED i
I ITEMS
structure is not intended or offered for sale (Section i • I I TOTAL 93 m 0.0
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK 93.00
I hereby affirm that there is a construction lending agencyCHANGE0130
for the performance of the work for which this permit is Dipartment
ION OF BUILDING AND SAFETY
issued(Sec.3097,Civ.C.).
Lender's Name loi County Engineer
PROPOSED MAX. OCG. APPROVED 0000-01001 ,y/ 6/91
Lender's Address UNSI R ORDINANCE No. 2225 N.S.
I certify that I have read this application and state that the PERMIT FEE r Q I °344 1 Ali 8:50
above information is correct.1 agree to comply with all County ISSUANCE FEE 13 ,00 ....
.. I
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEEno ! MQR i 7 1990
up-on 9 e above-mentioned property for inspection purposes.
O SEE REVERSE FOR EXPLANATORY LANGUAGE This set of plana and specifications MUST be kept
�� r r on the lob at all times and it is unlawNi to make
Signature of Permittee c Date anyctwngas or from
terationvision ewithoutwritten
and
ermission from the Division of Building and
Octy,CountyofLos Angelas.