HomeMy Public PortalAbout9532 WENDON ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS A P P L I C AT I O N
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I Hereby affirm that I have a certificate of consent to self CE 875 (11-84)COUNTY OF LOS"ANGh-LES BUILDING AND SAFETY DIVISION QUI
insure, or a certificate of Workers'Compensation Insurance,or
a cfrtified copy thereof(Sec. 3800,Lab.Q.
Policy No. Company FOR APPLICANT TO FILL IN FR
G 1)v\S �3?j �• 6-4 LA J..\
Certified copy is hereby furnished. BUIL°'NG 2 p��O►I Y �� C1
ADDRESS �/� /I+�(
DCertified copy is filed with the county building inspection LOCALITY C T
department. A, T.
Date Applicant NEAREST nCOT
/� r'1 T NO. GROUP I'-'NIST.
YPRO SED BY
CROSS ST. VCO �'IGS 2
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �j�jJ
COMPENSATION INSURANCE DESCRIPTION LOT NO. 3 BLOCK 91T11Z HIGHWAY
(CIRCLE) STATE MAJOR SEC D LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT a E SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE of - /N!CcSIZE OF LOT EXISTING BLDG. 4 I certify that in the performance of the work for which thispermit is issued, I shall not employ any person in any manner OWNER V, �/� D `'so as to become subject to the Workers' Compensation Laws. MAIL UPANCY GROUP o
ADDRESS S, Z E FM ! I.—
Date Applicant I„
NOTICE TO APPLICANT: If, after making this Certificate of CITY (� ��7 C�}, NE. l OCCUPANT LOAD y
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
With comply With SUCK provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION' Panic Devices
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- NO. OF EXITS
ness and Professions Code, and my license is in full force and 1 ^ J� ,{
effect. Adds, 7 (� ` "T0 eK 41 dUt4 PARKING READ PROVIDED
License Number Lic. Class t/e�'. I0 lA SPACES LIMITED TIME USE
Contractor Date \ ✓Ie `T DATE DATE
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF FROM: To: INSPECTORS
acting in my professional capacity (Section 7051, BUS- EXISTING BLDG. STORIES SIGN _URE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
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
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
❑ 1, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE G 4 • T=
ordinances and State laws relating to building construction,
/and hereby authorize represeptatives of this County to enter TOTAL FEE JS
upon the above-mentioned prderty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
/ Signature of Pere Date