HomeMy Public PortalAbout9442 KENNERLY ST_Miscellaneous__ WORKEitS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self
insure,;or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES' BUILDING AND SAFETY DIVISION u
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FORATO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING LOCALITY
El ADDRESS
Certified copy is filed with the county building inspection LOCALITY �� AA - /� NEAREST11
department. /jam, 41
C/ CROSS ST.
Date Applicant NEAREST �/ DISTRICT�NQ. GROUP TYPE P CESSED BY
CROSS ST. / aavv 3 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. /t7t BLOCK MAP HIGHWAY
NO. (CIRCLE) ST AT E•MAJOR SECOND LOCAL
NO. OF BLDGS.
(This Section need not be completed if the work involved TRACTNOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) uSE OF
I certify that in the performance of the work for which this SIZE of Lor `/7 EXISTING BLDG. �
0
permit is issued, I shall not employ any person in any manner OWNER 5 7-so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP a2�1 ADDRESS 1--'
Date Applicant LL0
NOTICE TO APPLICANT: If, after making this Certificate of CITY TOL OCCUPANT LOAD
Exemption, you should become subject -to the Workers' APPLICAT ON FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. I '
OCCUPANCY INSPECTION Panic Devices
LICENSED CONTRACTORS DECLARATION
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 . PARKING REQ'D D PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date A awCS DATE DATE
FROM: TO:
El I am exempt from the licensing requirements as I am a
INSPECTOR'S
g
licensed architect or a registered professional en ineer IZE OF No O g
acting m my professional capacity (Section 7051, BUS- IS
BLDG. STO Es SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
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 ACCT.
v
License Law for the following reason (Section 7031.5, Busi =�3��7 ^17°70
P
nd Professions Code): NO. PARKING `-, as owner of the property, will do the work and the SPACES PROVIDED i ITEMS't 1 I GI 1�:
structure is not intended or offered for sale (Section Ti�7at ��
7044,Business and Professions Code). /
CONSTRUCTION LENDING AGENCY PROPOSED SE OF BUILDING CHECK 227°70
I hereby affirm that there is-a construction lending agency CHANGE °Q[I
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name '11/2L/9--
PROPOSED MAX. OCC.
Lender's Address 1 1 p��H o ii
PERMIT FEE ��bra D -I1
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,
and hereby authorize representatives of this County to enter TOTAL FEE a 0
upon th bove-mentio ed property for inspection urposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ermittee Date