HomeMy Public PortalAbout9236 PENTLAND ST_Miscellaneous__ WORKER -OMPF;NSATIONDCCLARATION - MISCELLANEOUS APPLICATION {�
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1 hereby a rn that I have a certificate of consent nc sell CE
in875" (7194 )sliice
e, or a certificite of Workers'Compensation Insurance,or COUNTY OF LOSANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec 3800, Lab C) —
Policy No Company FOR APPLICANT TO FILL IN BUILD INa Z
AO DRESS
6 fAt9_AP,4)
Certified copy is hereby furnished 1 Boca Ben i'/../ 'r LOCALITY
ElCertified copy is Filed with the county building inspection LOCALITY NQww SSr '
department . L>� G 'T cwoae aT
Date Applicant nSwREST I DISTR ICT NO O U TYFH RROCO.E. MY
CRO65 ST � -r ONS• ,
CERTIFICATE OF EXEMPTION FROM WORKERS' - (� (///
eOwL
COMPENSATION INSURANCE D..... N LOT No BLOCK •. / .•
¢o u¢Cl¢) STATE MAIOR SQ ONO LOCAL
NO OF RLOOB
(This ReCtlOn need AOI be completed If the Work involved TRACT NOW ON LOT UBH ONH aFH CIwL CONDITIONS
by the permit Is for one hundred dollars (5100) or less)
SIZE OF LOT QO H%ISTIND wLO.
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any-person in any manner OWNER S '
so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP _ o
•DOR Q89
Date Apphcantm�r^ C w
NOTICE TO APPLICANT If, after making this Certificate of CITY /gyp TEL 6�1 X30, OCCUPANT LOAD a
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be ❑ ❑ No Spec Know[
deemed revoked rwwuee us¢ aeouoaY INSPECTION
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION;g Panic Devices
1 hereby affirm that 1 am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busr No of EXITS
ness and Professions Code, and my hcense Is in full force and
effect PARKING
SPACES REO O = F
ROVI... D
License Number Lie Class D
LIMITED TIME USE
Contractor Date— '� D.TR D.T.
I am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer SIZE of ST oP 151 cTUR a
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG NO OF
g� sI wrRE
mess and Professions Code) Date FINAL APPROVAL tel/
Lie Or Reg No PRESENT u9H of auILDlnc C/
HOME OWNER-BUILDER DECLARATION NO of EXISTING BUILDINGS '
ON LOT AND USE
1 hereby affum that I am exempt from the Contractor's _ _ ;26999A
License Law for the following reason (Section 70315, Bust
ness and Professions Code) No PARKING _ # 8 0
❑ 1, as owner of the property, will do the work and the SPACES PROVIDED „ ( BQS�O
structure is not intended or offered for sale (Section , . . •'•
7044,Business and Professions Code)
ti
• v •
CONSTRUCTION LENDING AGENCY PROPOSED LIES of BUILDING - � ' 8Q5 025
I hereby affirm that there is a construction lending agency OS O8)-87r
for the performance of the work for wluch this permit is • s x
issued(Sec 3097,Cry C) �
Lender's Name '
PROPOSED MAX OCC
Lender s Address 70.
I certify that I have read this application and state that the PERMIT Fee
above information is correct'1 agree to comply with all County ISSUANCE FEE 0
ordinances and State laws relating to building Construction,
and hereby authorize reprIesentat s of this County to enter TOTAL FEE
upon the above-men e prop for inspection purposes
p SEE REVERSE FOR EXPLANATORY LANGUAGE
r
Sign it f P mittee Date