HomeMy Public PortalAbout9580 KENNERLY ST_Miscellaneous__ WORKERS COMPENSATION DECLARATION , CE 875(2-80) MISCELLANEOUS A'PPLICATION `fl
I hereby affirm that I have certificate of consent to Self COUNTY OF LOS 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 BUILDING pDD RESS
- -
Certified copy is hereby furnished a BUIELDING �O LOCALITY
❑ ' ADDRSS
Certified copy is filed with the county building Inspection NEAREST
department LocwurY t. CROSS ST
Date Applicant NEARESTDISTRICT NO R P TYPE PIPZSED BY -
CROSS ST elava CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP 1 HIGHWAY
NO • (CIRCLE) STATE MAJOR SECOND LOCAL
(This kction need not be completed if the work InvolvedTRACT NOW ON LOT NOOF LO S USE ZONE SPECIAL CONDITIONS n
by the permit is for one hundred dollars ($100) or less) USE OF U
SIZE OF LOT EXISTING BLDG
I certify that in the performance of the work for which this i O
permit is issued, I shall not employ any person in any manner OWNER , _
so as.to become subject to the-Workers' Compensation Laws MAIL +6 P t C+ OCCUPANCY GROUP U
ADDRCj Q
Date Applicant ESS
NOTICE TO APPLICANT If, after making this Certificate of CITY NOL = 1, OCCUPANT LOAD
Exemption, you should become subject to the WorkersAPPLICA ION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth- ,
with comply with such provisions or this permit'shall' be TRAILER USEGEOLOGY INSPECTION
deemed revoked ❑ C] No Spec Knowl ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I_hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (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 SPACES REQ'D O PROVIDED D
� ^
License Number Lic Class T
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 /� /`/ /INSPECTOR'S
acting In my professional capacity (Section 7051, Bus- I EXISTING BLDG - STORIES , �3 V �iGr (/�e 16NATURE
mess and Professions Code) ]FINAI $/AP9R0VAL /✓`
PRESENT USE OF BUILDING `
_A(f
LIc or Reg No Date V
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
z ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Busi- a4
ness and Professions Code) rvo PARKING 2 27 /l
SPACES PROVIDED , 7, r1
❑ I, as owner of the property, will do the work and the - # e o o 0 3 0
structure is not intended or offered for sale (Section
I
7044, Business and Professions Code) PROPOSED USE OF BUILDING - 2 o'e 8 0, 6 O
T
CONSTRUCTION LENDING AGENCY 'a'a 0 8 0,16 0 v
I hereby affirm that there Is a construction lending agency, '
for the performance of the work for which this permit is 0614—'83
issued (Sec 3097,Civ C)
Lender's Name PROPOSED MAX OCC
Lender's Address PERMIT FEE Q�
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 4�
ordinances and State laws relating to building construction, TOTAL FEE ✓rte/
and hereby authorize representatives of this County to enter �/ V
uponeQabove-mentioned pr perty for mspectlon p)urposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date