HomeMy Public PortalAbout9252 KENNERLY ST_Miscellaneous__ Wn!,KERS'COMPENSAT•ION'DECLARAT,ION ' 4'
k 76M44CE 875 (2-801 MI�S•C=ELLAIV:EOUS A►PPLICATIO'N;. •
r '1"I lereby affirm tha£'I have a certificate of•cons`ent to self 'COUNTY_ OF L;OS ANGELES BUILDING AND SAFETY'DIVISION "
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof"(Sec, 3800;'Lab.C.) " " " -
-.Policy_No. Company FOR APPLICANT TO FILL IN` BUiLO1NG
F-1
}- ADDRESS • Fr
Certified copy�is hereby Lfurnished. BUILDING LOCALITY-
` I ADDRESS" _ • LI'm _
' ❑ Certified copy Is filed with the coonty,building inspecti,,on' '" TM NEAREST I ,' ,
�`�'� > _ LOCAL'ITY - -CROSS`S T. '-
department.' , i
Gig.- ;�. _ .
<-Date Applicant` NEAREST Q DISTRICT NO.' G OUP TYPE PR C SSED'BY i
• ',' CROSS ST.'S Y• _ CONST. '
CERTIFICATE OF EXEMPTION FRONT{WORKERS' LEGAL: I
'`D ESC RIPTION' 'LOT NO. ' f '_ BLOCK ,O 'h` '.MAP HIGH WAV ' - ' ~
COMPENSATION INSU,RAIVCE' + STATE MAJOR SEC LOCAL a
.. . NO.. VW (CIRCLE)- - O
NO..OF BLDGS.
' (This,section; need not be cornpletedjf-the Work lriVOlVed TRACT " NOW ON LOT USE'ZO SPECIAL CONDITIONS'- `
by the'permit 'is'.for one hu'ridred dollars ($100) or less'.), �. _ , U
LISE'OF
SIZE OF LOT"_ '� EXISTING BLDG. I= !11' - _ O t
I certify that in the performance)of"the'i`vork for,which this Y " '
;permit Is-issued, Lshall not employ any-person in.any%manner' OWNER
so 'as.to become subject to the W rkers' Compens n Laws. OCCUPANCY GROUP ,�/ W.
MAIL
/ ADDRESS r ,i- d
Date APPlicant 1� � � -� -'
v SEL[ Zz
NOTICE TO-APPLICANT: If, after,mak12
ing-this-Certificate of, clrY "' yl me OCCUPANT`LOAD•
Exemption,- you- should-•become subject•;to ,the•,Workers' • APP,LICATI FOR `'EXIT HARDWARE: '
Compensation-provisions of the Labor Code;you m6st,.foith: _ -
with comply with, such pyo visionsi'or,,,tlris permit shall be' - TR:AILER USE GEOLOGY INSPECTION. - No,S Spec.-'Knowl.. ❑ -y '••�` - '
deemed revoked. s ❑ x - P
Panic Device's ❑
i` OCCUPANCY INSPECTION may' .'1'.
LICENSEO.CONTRACTORS DECLARATION' L� ,
I hereby'affirm that I am-licensed under provisions of'Chapter" SAFETY PERMIT q (LIST ITEMS BELOW) ry0. OF EXITS
9 ,(comrriencinIg with.Sectiori 7000) of-Division-3-of the'Busi-
ness and,,Professions Code, and my license is-in full force and YL -Aj (,+jr PARKING.' ,
effect. v 1 - REO'D ;� •PROVIDED
- _ SPACES-
License Number Lic.Class ^" i- C- — `LIMIT .TIME(.OSE
Contractor " Date C GATE DATE*,
FROM' 'TO'
❑ '.I am exempt from.-the licensing.requirements as I am a;." )'C * !' 7l3
licensed-'architect- or a 'registered professional engineer SIZE OF (� NO. OF )NSP CTOR'S
acting'm my professional capacity (Section'7051,.Bus- - EXISTING BLDG, IA/ STORIES "sl ATURE-
iness and Professions Code). PRESENT U5E OF BUILDING a FINAL APPROVAL /n A
Lic:or Reg.No. Date
HOME OWNER-BUILDER bEGLARATION NO.OF EXIS,TING•BUILDINGS' ;S sem.
_ , y ON LOT AND USE _ - . - �•�
I' hereby affirm that, I am' exempt, from the Contractor's 5 A;-
License Law for the following reason*(Section 7031 5, Bus]'- e o••,• •
ness and:Professlons Code): NO. BARKING
"' � SPA'C ES PROVIDED,
'❑ I', as owner of the property;willldo the work and the
structure is not intended or-offered,:for,sale,(Section
7044, Business and'Professions Code).. o„• !3,$Q 5 Q,5
_ PROPOSED USE-OF,'BUILDING -, -
CONSTRUCTION LENDING A'G'ENCY' '
I hereby' affirm that there is a construction lending agency Q'2;4',-$ =
for. the performance of the'work for which this permit is'
issued(Sec. 3097,Civ.C.).
Lender's'Name PROPOSED M'wrt. occ: + '
Lender's Address' PedMli FEET
1 ,
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, TOTAL- FEE [ �q
and:hereby authorize•representatives of this County to enter V 110
upon_t a above-mentionederty`for in purposes. SEE REVERSE'FOR EXPLANATORY LANGUAGE c '
T
15afe
Signature of Permittee {/ LI