HomeMy Public PortalAbout9556 KENNERLY ST_Building__ • WORKERS' COMPENSATION DECLARATION
ihereynsure boraafirm certif cathane of Workers' Compensation Insurance, APPLICATION, FOR BUILDING PERMIT
or a certified copy thereof (Sec.%3800, Lab•. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING `,
tion department. ADDRESS �/ �p K /
Date Applicant CITY 1 �l ZIP 1•� 1 LOCALITY
NO. OF BLDGS. NEAREST.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE�/ PARCELO/A
hundred dollars ($100)or less.) T 'EL. q // USE ZONE MAP U 6
OWNER NO. z b NQ �/
I certify that in the performance of the work for which this y�
permit is issued, I shall not employ any person in any manner ADDRESS 6 ff�>/ SPECIAL a-
R-1 CONDITIONS O
so as To become subject to The Workers'Compensation Laws. e�-�
CITY 1 ZIP U
Date Applicant ARCHITECT OR TEL. DISTRICT. GROUP TYPE FIRE PROCESSED BY CY
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO.
CONST. ZONE 0
Exemption, you should become subject to the Workers' ' /
Compensation provisions of the Labor Code, you must forth- ADDRESS ��� 3 !/ w
a_
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR NO. �j � Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of The Business '
LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASSgK. PG: VALIDATION
SQ. FT. OF NO. OF CHECK`
License Number Lic. Class SIZE STORIES FAMILIES A' ONE
VALUATION D p
Contractor Date
DESCRIPTION O�WORK NEW
D ® S 1—7 j,���� Z7 T G
❑I am exempt under Sec. P �`" `"11 ❑ L 1 ► -
B.&P.C. for this reason CMA A
a� ALTER
T� :"� 7� 1A<"\) REPAIR ❑ $ r'•"`•8 `"
Date: USE OF -:I
EXISTING BLDG. DEMOI .
Signature t APPLICANT �* /y� y TEL. /
(PRINT). Moe o( /,W*J& NO. FINAL
_
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License i€-9 t'� ='t fr6 � '='t13
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL r•tti,.);
Professions Code): PRESENT By - L==`• _"a'_1
❑ BUILDING ifg N3ukI, as owner of the property, or 'my employees with
ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions.Code.) MOVING TEL. -
❑ CONTRACTOR NO.
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- o..fij
ADDRESS 1
tion 7044, Business and Professions Code.) '@y
REQUIRED TOTAL SETBACK FROM jE
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE
L.
I hereby affirm that there is a construction lending agency for FRONT. F '
the performance of the work for which.this permit is.issued P.L.'
(Sec. 3097, Civ. C.), SIDE
Lender's Nome,
m P.C..Fee$ Permit Fee LPerm.
Lender's Address1 certify that I have read this application and state that the Issuance Fee above information is correct. I agree to comply with all County Investigation Fee
R ordinances and State laws relating to building construction, Total Fee J' ,
a and hereby authorize representativesof this County to enter
upon the above-mention ed.prop rty for inspection purposes.
CILa
.o t —�2— _ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of A plic•' t or Agent / Date