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HomeMy Public PortalAbout9561 KENNERLY ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) m I SC E�L LA N E O U S APPLICATION I hereby affirm ,that I have a certificate of consent to self COUNTY OF LOS ANuELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or r a certified copy thereof(Sec. 3800,Lab.Q. i- Policy No. Company FOR APPLICANT TO FI LL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING �� � �NCi�� ADDRESS LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. G OUP TYPE �✓ PR ESSED BY CROSS ST. -� CONST.T/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) usE OF SIZE OF LOT EXISTING BLDG, d I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER D080r14 so as to become subject to'the Workers' Compensation Laws. _ OCCUPANCY GROUPMAIL ERE ADDRESS y�"/j 5T- O Date Applicant GW I NOTICE TO APPLICANT: If, after making this Certificate of CITY NE-4 OCCUPANT LOAD N Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPL CATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION E] Panic Devices El 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- ness and Professions Code, and my license is in full force and effect. I l PARKING REq D PROVIDED SPACES J License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF I SSPECTURE acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code). PRESENT USE O BUILDING FINAL APPROVAL I`//f,�. . 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 859© ®J� _ _7 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED ' a' I, as owner of the property, will do the work and the s ''EM__ structure is not intended or offered for sale (Section _ 7044,Business and Professions Code). ' ` ',ti!H_ 227 PROPOSED U OF BUILDING 1:,S-'I; •i' � a i??I CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency _3ktl€ltat for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. I%I�„:_i t" t Lender's Address PERMIT FEE i� i;S�tAm 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 �� 7 7c up n the abo�mento ed. ropert I for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE - Z Si nature of Permittee Date