HomeMy Public PortalAbout9465 PENTLAND ST_Miscellaneous__ OFThLGS'COMPENSATIONDECLARATION CE 876 MISCELLANEOUS APPLICATION
CE 876 (t 1 84) J�
I hereby affirm that I have a s'Compensation
of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION ',lull
insuxq or a certificate of Workers'Compensation Insurance,or
a certifted copy thereof(Sec 3600,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BNI
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Certified copy is hereby furnished wcowcs8 9465 Pf.N TG/4'/VO LOCALITY / ,C 1/ /, —' " /
Certified copy is filed with the county budding inspectionLOCALITY �/�j0� (�� NE wR¢8T
department uROSaST ® GLOYF2LY
Date Applicant NEAREST /� / `/[''� t/ D18TR1 NO a OUP TYPE C¢99CO BY
c¢osa at- r�L/� VUCL/ O O -� cCINST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o (/
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCKC` HIGHWAY
//pp11,� � NO OP ELOOS
KO (CI CLR) STATE MAJOR SECOND LOCAL
by perm t se need not be completed if the work involved TRACT Now ON LOT US¢ zon¢ 9.¢CIAL CONDITIONS '
by the permit is Cor one hundred dollars (5100) or less)
uee OF S¢¢ of Lor ex Iasi na BLDG
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Icertify that in the performance of the work for which this A„ /�p
permit is issued, I shall not employ any person m any manner OWNER 7-6 I (..Ax D05,C y
so as to become subject to the Workers' Compensation Laws OCCUPANCY GROUP 3 0z
wODRHsa 9�GS 10264 TGA"D O
Date Applicant LU
NOTICE TO APPLICANT If, after making this Certificate of CITY 7 C. Riot OCCUPANT LOAD
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY IaSPEcnoN ❑ No Spec Knowldeemed revoked
` LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
1 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 Bust- NO OF EXITS
ness and Professions Code, and my license is m full force and
effect /fEA T/l1/6 - A-/K LOAD/7/0A.41 PARKINS
S.ACHB REGD I� PROVIO¢D
License Number Lic Class
' LIMITED TIME USE
Contractor Date - _ - DAT. DA Tw
1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OFINSPECTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG NO OFS SIGNATURE
No OF '
mess and Professions Code)
Date PRESENT use of BUILDING
FINAL APPROVAL
Lic or Reg No
IS
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS
ON LOT AND USE
1 hereby affirm that 1 am exempt from the Contractors
License Law for the following reason (Section 7031 5, Buse- _ 1_
ness and Professions Code) NoPARKING 17 lilt
1, as owner of thero rty, TEf7 will do the work and the SPACES PROVIDED _ I
P
structure u not intended or offered for sale (Section J
7044,Business and Professions Code) )j i7�L V`
- 00
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is !HA0GE
issued(Sec 3097,Civ C)
Lender's Name
Lender s Address
PROPOSED MAX OCC 111111(I�fl('�lt
PERMIT FEE
1 certify [hat I have read this application and state that the �' =516 1 rin T•y`
above information is correct 1 agree to comply with all County ISSUANCE Fee - ;(
ordinances and State laws relating to budding cons[xuchon,
and hereby authorize representatives of this County to enter TOTAL FEE I
upon the above-miitioned property for inspection purposes ,
Z7 / 9 SCE REVERSE FOR EXPLANATORY LANGUAGE
3
Signature of Permittee < Date J? '
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