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WORKERS'COMPENSATION DECLARAY[ON 76M444 M ISC E L LA N EO U S A PPL ICAT 10 N �
. CE 975(2-801
[ nereby affirm tnat [ ����e a certificate �t consent to se�f , COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure,ur a certificate of Workers'Compensa[ion[nsurance,or ��,
a certified copy thereot(Sec.3800,LaA.C.) �/
Yolicy No. Company FOR APPLICANT TO FILL IN noo.csso�(F.�i 5" �.�.Qa�-u/
� Certified cnpy is hereby furnished. aui�mN�
4��RE55 LOCALITY � ' �
� Certified copy is Filed with the rounty building inspection �
LOCALITY c6ARE5T �/
department. ` 2 � rsoss sr. .�C.Ld.L,
Uate Appiicant nEwwssr O�STRICT NO. GRO TYGE��/ PROC S6C 9V
CRDSS ST.�1 h y(j� N� /^ �f� CD�'1rr//_
CERTIFICATE OF t:X6MPT[ON FROM WORKERS' �s�^� �� �� �
COMPENSATION INSURANCE OESCRIPTION LOT NO. B�OCK ,,,, ,�ww. }
no./O,�— ,�j (c�Rc�EI arwre MAJOR 6ECON oc• a
NO.OF BLDGS.
�T�1IS SCC�IOII need not be completed iF the WOI�C 111VO�VEI� TRACT �7 NOW ON 40T O�(` USE ZONE SPECi/IL CONDITIONS U
by the permit is for ane hundred dotlars ($100) or less.) usE oF �' �
SIZE OF LOT , 2 EXISTING BLUG. � � O
t certify that in the performnnce of the work for which[his F
permit is issued,I shali no[emptuy any person in nny manner OWNER � C�
so as Io 6ecome subject to the Workers'Compens�tion Laws. Mp�� � � OCCUPANCY GROUP W
wnoAess '1 1 iJA a
Date Applicant N
NO'iiCE TO.4PPLICANT: If,after making this Certificate of eirv y^ Na�� � OCCUPANT LOA� ?
Exemption, you shuuld become subject tu the Workers' qppUCATION FOR EXIT HARDWAflE:
Compensation prnvisions of the La6or Code,you must forth-
with comply with such provisions or tAis permit shail be TRAILER use GEOLOGY INSPECTION
deemed revoked. � ❑ fVo Spec.Knawl.
LICENSGU CONTRACTORS DtiCLARATIOti �CUPANCY INSPECTON Panic Devices ❑
[hereby affirm that I em licensed under provisions of Cha�ter 9APETY PERMIT q I�isr ITEMS 6ELOWI �
9 (commencing with See[ion 7000)of Division 3 of the Busi- no.ow Exirs
ness and Professions Cude,anS my�license is in full furce anJ --"- --
effect. �+-� PARKING� REO�D � PROVIDED �
SP�CES
License Number Lic.Clxss
L�MITE� TIME USE
Contractor Date o..E oarE
� I am exempt from the licensing requirements as I am a ._
licensed archiiect or � registered professional enginecr s�ze oF no.oc INSPECTOR�S
acting in my professionat capacity (Sectiun �OS2. BUS- ExlsT�nG BLD6. STORIES 516NaTUw6
iness and Professions Code). rxesenr use oF euuo�rvc FINAL APPROVA4 pµ'r
Lic.or Reg.No. Uate /`� 6 I '�
HOME OWNIR-BUILUER DECLARATION H�•OF CXISTING BUILDINGS
ON LOT AHO USE
1 hereby nffirm that�I am exempt from the Cuntructor's
License Law for the fullowing reason (Section 703L5, Busi- �
ness and Professions Code): No.rawKir�e
SP/�GES FROVIOEO �0 9 3;3 A
� [, as owner of the property,will do the work and the
structure is not intended or offered for sale (Section
7044,Business and Yrofessions Code). tt• � ��3 Q
PROPOSEO USE OF BUILOIN6
CONS7'RUCT[ON LENUING AGtiNCY �.� �8 a��
1 hereby affirm that [here is a construcCion Iending agency • • •$Q 5 O�
for the perfurmance of the work for w�ich [his permit is , .
issued(Sec.3097,Civ.C.).
Lender's Name ����9�$�l
PROPOSEO MAX.pCC.
Lender's CSS PERMIT FEE • � O
I c y thut I have read thix appl •ation und s[u[e thet the
u ve information is correct.I agree o comply with ali Cuunty �SSVANCE FEE
�rdinances and State tuws relati to building CO�SS�uCtlOn, TOTAL FEE p
and hereby authorize represent ves of th�s County to enler
upon the above-mentioned pr erty for inspection purposes. SEE R�:VERSE FOR EXP[,AN.4TORY LANCUAGE
_ —� � i-9-fl'�
Sigt� ure of ' tee Date
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