HomeMy Public PortalAbout9002 PENTLAND ST_Miscellaneous__ WORKERS COMPENSATION DECLARATION . 78104" -
1 CES7512801 MISCELLANEOUS 1'�>-
APPLICATION .•, {�
I hereby affirm that I have a certificate of consent to self 1COUNTY OF LOS ANGELES BUII;DING AND SAFETY DIVISION
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Insure or a certificate of Workers Compensation Insuranc•,or
a certified copy thereof(Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL'IN BUILONG
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❑ Certified copy Is hereby furnished - ~ euILD wO' LOCALLY
ADDRESS
❑ Certified copy B filed with the county budding mspecllon NEARa9T '
department LOCALITY �C—� cwos$ISY
e 1� n NEARQ6T O16TRICT ry OR UP TYPE IR CISCO BY
Date Applicant - ,
CPO Qf ST ` CONS
CERTIFICATE OF EXEMPTION I-ROM WORKERS LEGAL
DESCRIPTION LOT NO BLOCK �, jn ILEI STATE MAJOR a orvo LOCAL
COMPENSATION INSURANCE .0 a
I NO OF SLOGS
(This Se tion need not be Completed if [he work involved TRACT ` J NOW ON LOT / us E LONE aP ECIAL CONOITIONB - O
by the permit Is for one hundred dollars (5100) or less) _
^ / UBE OIN
' s , f 912E OR LOT�r X�O� HxIST" BLDG �5
1 certify that In the performance of the work for wh¢n this O
permit is L.sued I shall not employ any person In any manner OWNER H _ 1 U
ISO is to heco a subject to the r rs Com ieI Laws OCCUPANCY GROUP i� W
MAIL\ y�
ADDRESS ����/ • ." • r U)
rDat Applicant /
TI L T APPLICANT If+after i laking this Certificate of CITY �- `j NOL ���� r OCCUPANT LOAD Z
Exemption, you should become subject to the \Yorkers gppL CATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth `
with comply with such provisions or this permit Shall he TRAILER USE❑ GEOLOGY INSPECTION C] No Spec Knowl Eldeemed revoked
I Panic Devices ❑
LICENSED CONTRACTORS DECLARATION,
occurwwcr IrvarecnoN
1 hereby afflrmithat I am licensLd under provisions or Chapter aw PHTY PERMIT q (LIST ITEMS BELOW) NO OF EXIT$
9 (co mmencing with Section 7000) of Dlvismo 3 of the Bust - -
ness grid Professions Code and my license Is In'full force andANP rh:Z7 emyPARKING
CtfCel - RCOD D PROVID HD
P/ Y arwc ea ,
Ltccnse Number Lte Class
- `LIMITED TIME USE
Contractor Date - DAT. AT.
I em exempt from the licensing requirements as I em a
licensed architect or a fLglstered professional engmeLr size OP
QQ No OF )NSPN TUR a
acting In my professional capacity (Section 7051, Bus- axis ING BLDG J y X STNo Rlea sl wrRe
mess and Professions Code) I I e FINAL APPROVAL
PRESENT USE OF BUILDING
Ltc or Reg No Date ,
# 30
HOME OWNER BUILDER DECLARATION NO ow Ex. rvc Bu1LolNca ��
1; ON LOT ANO U9H �•
I hereby affirm that I am exempt from the Contractor's 1 8 n 5 0
License Law for the following reason (Section 7031 5 Bust J 1
nress and Professions Code) 6PARKING
PAC ea rROVmHO 1/ XN 'Two e� 0 111 It 8Q5,00r I as owner of the properq will do the work +nd the-
X �
structure Is not Intended or offered for sale (SLCt Ion
7044,eBusmess and Professions Code)
PROPOSED USE OF BUILDING • �
y
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there Is a construction lending agency
for the performanLe of thL work for which this permit Is J s Y
1�i,;=
ed (Sec 3097 Co, C x ,
der's Name PROPOSED MAX OCC v
ders Address_ PERMIT FEE ere in that L hate read Ihrs Tee to con and state )hat theva information u correct I agree to comply with all County ISSUANCE FEEminces and State laws relating to buildin herebv authorize representatives of Ihrs Cmentlo property for Inspect m purposes SEF REVERSE FOR EXPLANATORY LANGUAGElgnatu Perml ee 1 D e J '