HomeMy Public PortalAbout9887 WENDON ST_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 876(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUIL ING-AND SAFETY DIVISION
.insure, or a certificate of Workers'Compensation Insurance,e,or '
&certified copy thereof(Sec.3800,Lab.C.). I
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
• ADDRESS
Certified copy is hereby furnished. Bu11DI11 O A II!-'- LOCALITY 7L
ADDRESS C
❑ Certified copy is filed with the county building inspection LOCALITY _9777T'.E A R R ST
department: C CROSS ST.
Date Applicant NEAREST \ I,' DISTR T NO-yWOUP TYPE P SSED B' CROSS ST. 'rG —J L VV E- , D v CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS ' LEGAL e
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT / dQ NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred.dollars ($100) or less.) use OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. a
Permit is issued,I shall not employ any person in any manner OWNER 1 _j 7� F 6 RIF _ � 7-1 o
J
so as to become subject to the Workers'Compensation Laws. MAIL OCCUPANCY GROUP 3 0
ADDRESS
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of cITYrE 10L CNOL.y18 (o_(o9,9LIOCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions oI this permit shall be TRAILER use ❑ GEOLOGY INSPECTION❑ No Spec. Knowl.
deemed revoked.
LICENSED•CONTRACTORS DECLARATION OCCUPANCY INSPECTION p� Panic Deyices
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
effect. PARKING REWD PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
I am exempt from the licensing requirements as I am a PROMI TOI
licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGN TURF
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING u
Lic.or Reg.No. Date
45
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 1 ITEM:
ON LOT AND USE
I hereby affirm that I am exemptfrom the Contractor's TOTAL 234 .45
License Law for the following reason (Section 7031.5, Busi
ness and Professions Code): NO. PARKINGirHE {i 2'14��: I
I, as owner of the property, will do the work and the SPACES PROVIDED CHANGE .00
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ry lylyr,r, B/ 4/9
I liereby affirm that there is a construction lending agency _ -�I(`� s i
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 ISS4 ANCE FEE 07�, fLp
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon th above-mentioned property for inspection p rposes.
SEEI REVERSE FOR EXPLANATORY LANGUAGE
j
S' ature of Per ee D to