HomeMy Public PortalAbout9424 KENNERLY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 -
CE875 (2-80) MISCELLANEO:US. APPLICA-TIOIN
I herebaffirm that I have a certificate of consent to Self COUNTY OF LOS ANGELES .BUILDING AND SAFETY DIVISION
•,insure;`oysr a certificate of Workers'Compensation Insurance,or _
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Compahy _ ' FOR APPLICANT TOTILL'IN BUILDING
ADDRESS
0 Certified copy is hereby furnished. BUILDING LOCALITY
ADDRESS KEEN rq ER L
Certified copy is filed with the county building inspection NEAREST
department . LOCALITY —�—Ern PLE C) CROSS ST.•
Date Applicant NEAREST /7 DISTRICT NO. GROUP TYPE' =PROCE ED BY
CROSS-ST., (�/�-� CONST./' *v
CERTIFICATE OF EXEMPTION FROM WORKERS'. LEGAL
DESCRIPTIONO: BLOCK MAP HIGHWAY
COMPENSATION INSURAN LOT NCE _ No. i4jo'l& (CIRCLE) STAT_E MAJOR SECOND LOCAL a
_ NO. 0F.BLDGS..
(This section need not be cdripleted if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O
by the- permit is forgone hundred dollars ($100)-or less.) U
_ USE OF,':-
SIZE
F.':-SIZE OF LOT - EXISTING BLDG.
I certify that in-the performance of the work for which this 0
permit is.issued, I shall not'employ any person in any manner OWNER '
so as to become subject to the Workers''Compensation Laws /- �-Lr^�l�.j C�J� OCCUPANCY GROUP'MAIL �' LU
V
.. ADDRESS
Date Applicant - N
/ EM PLGE' G TEL. Z
NOTICE TO APPLICANT: If, after making this Certificate of cITY NO. OCCUPANT LOAD
Exemption, you should be'come'.subject to the Workers' APPLICATION FOR EXIT HARDWARE
Compensation provisions of the-Labor Code, you must forth-
with comply with such�provislons or this- permit-shall-be TRAILER USE EJ' - GEOLOGY INSPECTION❑\ NO Spec. Knowl.•0. '
deemed revoked.
LICENSED CONTRACTORS DECLARATION occuPANcr IrvsPEcno Panic D@VICES ❑-.
I hereby.affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q° (LIST ITEMS-BELOW) '
NO.'OF EXITS,
9 (commencing with'Section 7000)•of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect. - RE PROVIDED
-- - SPACES O
License Number Lic.Class
LIMITED"TIME USE
Cohtractor Date DATE DATE
❑ - _ FROM:' TO• .
I am exempt from the licensing requirements as I am a
licensed architect or a registe'red-professional engineer SIZE OF ' NO. OF �� in—cc ��� SPE CTO R'S
in—cc
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
mess and Professions Code). PRESENT USE OF BUILDING FINAL' APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION No.•oF EXISTING BUILDINGSC1�P
SON LOT-AND USE
I hereby 'affirm 'that•-I am exempt from the Contractor's J z•9•6 9;� A
License Law-for the following reason (Section 7031.5, Busi- ^�(
NO. PARKING `# B O.O'O 3 0
ness and Professions Code):
SPACES PROVIDED
F] I; as owner bf the property, will do the work and the
structure is not intended or offered for sale (Section :2 0 0 8 0,`5 0.
7044, Business and Professions Code). "
PROPOSED USE OF BUILDING _ �O O.O 8 O 5 0 U
- CONSTRUCTION LENDING AGENCY [O 2•'1' 0`—'8 3
I hereby affirm that there. is a construction lending agency
for.the,performanceof the.work for, which this permit is
issued (Sec. 3097,Civ.C.).
Lender's Name PROPOSED Max. ore.
Lender's Address PERMIT,FEE 7
I certify that I have lead this application and state that the
FU
above information is correct. I agree to comply with all County ISSUANCE EE
ordinances and State laws relating to building construction, TOTAL' FEE S0
and hereby authorize representatives of this County to enter
upon ebove-mentioned prop e ty for inspection purposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date