HomeMy Public PortalAbout9888 WENDON ST_Miscellaneous__ WORKERS'CO1viPENSATION DECLAR�A, 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 certifiiate of Workers'Compensation Insurance,or i
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. V ADDRESS Company FOR APPLICANT TO FILL IN BUILDING cb- v be, J-6 LA
Certified copy is hereby furnished. \ BUILDING !
ADDRESS (� y /� LOCALITY
D a r ifie ecopy is filed with the county building inspection LOCALITY ���4� ��T ?/ G� NEAREST
/• CROSS ST.
Date Applicant NEAREST Dri .ICT NO. OLP TYPE CONST. P SSED BY
CROSS ST. L��0b I ro;J
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL - �J V 111
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAF HIGHWAY
No. (CIRCLE) STATE MAJO SWCaJ LOCAL
NO. OF BLDGS.
(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. d
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER ��IIT C--
s'
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
Date Applicant
ADDRESS Ste}/Gr 113
IJ.I
TEL'
NOTICE TO APPLICANT: If,after making this Certificate of CITY No. N
OCCUPANT LOAD
Exemption, you should become subject to the Workers' iS
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply With such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
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 GG //�/ /�/l
effect. el G Y� F�/y ��� PARKING
SPACES REQ'D D PROVIDED D
License NumberLic. Class ��dd�H T �T/W jc
LIMITED TIME USE
Contractor Date ■ DATE DATE
ElI am exempt from the licensing requirements as I am a PROM: TO:
licensed architect or a registered professional engineer\ SIZE OF NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, BUS- \ EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL 3-I9 q 1
PRESENT USE OF BUILDING Irl )V
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS -I
• ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's (;;of
License Law for the following reason (Section 7031.5, Busi
ness and Professions Code): NO.SPACES PROVIDED PARKING ;l ye;�i�'F
ElI, as owner of the property, will do the work and the .I r-:n
structure is not intended or offered for sale (Section ! r NG
7044,Business and Professions Code). TOTAL 2-734 @ 4
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK 2
3
4=T5
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CHANGE .00
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the 2� �S 4101O I AM
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE S
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date