HomeMy Public PortalAbout9842 WENDON ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875(11-84)' MISCELLANEOUS APPLICATION
I hereby affirm that I have a 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.). / (V ,/
Policy No. Company FOR APPLICANT TO FILL IN BUILDING IL /D�p(
ADDRESS ��E l
Certified copy is hereby furnished. BUIL°'NG('
ADDRESS LOCALITY —
❑ Certified copy is filed with the county building inspection LOCALITY' NEAREST
department. LEC CRDs. ST.
Date Applicant NEAREST DISTRIC O. G lyi� TYPE P CESS BY
CRO53 ST. P --1 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL `✓]
COMPENSATION INSURANCE DESCRIPTION Lor No. BLOCK MAP HIGHWAY
NO. (CIRCL.E) STATE MAJOR 5 CON LOCAL
NO. OR ]SLOGS. '
(This section need not be completed if the work involved TRACT' NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
SIZE OF LOT EXISTING BLDG.
I certify that in the performance of the work for which this e
permit is issued,I shall not employ any person in any manner OWNER y
so as to become subject to the Workers' Compensation Laws. 50 OCCUPANCY GROUP
MAIL o
ADDRESS
DateApplicant
W
TEL' OCCUPANT LOAD
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. 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 such provisions oI this permit shall be TRAILER USE 0 GE?LOGY INEE] No Spec. Knowl.
SPCTION ❑
deemed revoked.
EJ
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIO Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (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
effect.effect. 7' PARKING SPACES
REq'D PROVIDED
License Number Lic. Class 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
79)
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATU
iness and Professions Code).
� (I�
PRESENT USE OF BUILDING FINAL APPROVAL
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 ACCT..
License Law for the following reason (Section 7031.5, Busi 33107 9L.0133ness and Professions Code): NO. PARKING
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the 1 ITEMS
structure is not intended or offered for sale (Section
7044,Business and Professions Code). TOTAL 93.01
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK D,l
9`
I hereby affirm that there is a construction lending agency C'I••(AH6E .00
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name (, {•� {y{
PROPOSED MAX. OCC. 0(}00-0 01 31/14/90
Lender's Address 6n.00 1 {
'I certify that I have read this application and state that the PERMIT FEEti7 i' {(�
above information is correct.I agree to comply with all County ISSUANCE L13
D
ordinances and State laws relating to building construction,
and h eby authorize representatives of this County to enter TOTAL FEE 3�
Awt5w
r inspection purposes.
_�` SEE REVERSE FOR EXPLANATORY LANGUAGE .
Signature of Per tee Date(l