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Home My Public Portal About4916 RIO HONDO AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION hereby as cert that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION nsure, or a certificate of Workers'Compensation insurance,or I certified copy thereof(Sec.3800,Lab.Q. ?olicy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS /` , Jo ,��,vr� Certified copy is hereby furnished. BUILDG l/, I7— LOCALITY ,° �9 r ADDRESINS •� 6 �L� / (J G_ Certified copy is filed with the county building inspection LOCALITYNEAREST department. V ��'= I` CROSS ST. Date Applicant NEAREST +� \ D1?1� O. GRIP ITYP PROC Et`Y CROSS ST. ) � ,6ucS� {�" CON CERTIFIIQATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. L.C. MAP HIGHWAY E) STATE MAJOR SEC D LOCAL No. (elRcl.e) J/ No. OF LOT USE ZONE SPECIAL CONDITIONS (This 50CtlOn need not be completed if the work involved TRACT/,6 Y-7 NOW ON LOT - 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 iL V � permit is issued, I shall not employ any person in any manner OWNER �L �� A�r�T ''�RM,4N LZ= Ar y so as to become subject to the Workers' Compensation Laws. MAIL ff �7 _ OCCUPANCY GROUP ADDRESS ^ ij X4v v Date Applicant TEL LU � 6 � NOTICE TO APPLICANT: If, after making this Certificate of CITY No. OCCUPANT LOAD Cl- 013 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 Or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑ ❑ ❑ No Spec. Knowl. deemed revoked. OCCUPANCY INSPECTION❑ Panic Devices LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS HELow) 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 t6 ^.1�� t'� G REQ D ^-J PROVIDEDeffect. SPACES License Number Lic. Class LIMITED TIME USE JJ 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'SGN E acting in my professional capacity (Section 7051, BIAS- EXISTING L.G.H ��, q STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL y� PRESENT USE OF BUILDING Lic.or Reg.No. Date h IJ P 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 usi ness and Professions Code): NO. PARKING -}•;-•T+.: ® i I I, as owner of the property, will do the work and the SPACES PROVIDED C.1•- structure is not intended or offered for sale (Section 234 . 45 7044,Business and Professions Code). 1-7. C CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECK 'r-,Ir I hereby affirm that there is a construction lending agency H plr °`11 for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name i_11i:( —I._l;l_i i -• -- PROPOSED MAX. OCC. Lender's Address =4 is PERMIT FEE .� I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE .� ordinances and State laws relating to building construction, r and hereby authorize representatives of this County to enter TOTAL.FEE upon the above-mentioned pro lerty for inspection purposes. ` SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION MISCELLANEOUS APPLICATION CE 875(11-84I 875 Is CE I hereby affirm-that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, gr a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDIN /� Aloe) v� ADDRESSG LOCALITY Certified copy is filed with the county building inspection LOCALITY - NEAREST department. CROSS ST. Date Applicant NEAREST.J D (� DISTRIC NO. GROUP TYPE PR CESSED BY CROSS ST./L.O C/� (ALIS ,� �J CONST/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a COMPENSATION INSURANCE DESCRIPTION I LOT NO.19 BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO.OF BLDGS. (This Section need not be completed if the work involved TRACT f �� NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) usE of �'�"�"� t/ SIZE OF LOT 6 1 X •Z'� EXISTINdJA' G/r+b J/y�j+ } I certify that in the performance of the work for which this v )J o permit is issued, I shall not employ any person in any manner OWNER 3A 4c .A,..D (G b a&& C-RJA so as to become subject to the Workers' Compensation Laws. MAIL ) /� /� _ OCCUPANCY GROUP ,% a ADDRESS �{ Rio 0/vdG Il Date Applicant '�+ "' NOTICE TO APPLICANT: If, after making this Certificate of CITY/�14`fPZ ! C 11`71 NOL - -!T.�.�S,7� OCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- APPLIC TION FOR EXIT HARDWARE: with comply with such 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 B effect. ?.1 -PGG PARKING REq D PROVIDED SPACES License Number Lic. Class LIMITED TIME USE Contractor Date 7Z DATE DATE FROM: TO: 0 I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S E g p 1>i Y �� ' SIGNATURE acting in my professional capacity (Section 7051, Bus- EXISTING BLD 6. /� STORIES iness and Professions Code). I ��L�.� e- FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date J (� HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ,r -I' ON LOT AND USE /� 8 I hereby affirm that I am exempt from the Contractor's ACC'"T _ License Law for the following reason (Section 7031.5, Busi- ness usi ness and Professions Code): NO. PARKING ❑ I, as owner of the property, will do the work and the SPACES PROVIDED y ITEMS structure is not intended or offered for sale (Section 7044,Business and Professions Code). irHL234- 45 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CHECKr„4 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.). j'( .}} Lender's Name PROPOSED MAX. OCC, i0100:_�—!191011 'f 13 ? Lender's Address ��PERMIT FEE rpt/ Jis: 1 AM L'"ri i I certify that I have read this application and state that the 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 FEE72) 1l7 L.0 upon the above-mentioned pro erty for inspecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signa re of Permittee D e