HomeMy Public PortalAbout4818 WILLMONTE AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent tself COUNTY OF'LOS ANGELES ,, BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,e,or I ,
a certified copy thereof(Sec.3800,Lab.C.). I �.
Policy No. CompanyBUILDING
FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished. BUILDINGj�
ADDRESS (J LOCALITY
Certified copy is filed with the county building inspection LOCALITY / NEAREST rJ
department. I, /.rl f'G E �/ cR 0 ST.
Date Applicant NEARE O
ST• // /1 DISTRICT N . GROUP TYPE PROCESSED BY
CROSS ST. •1/�/�t 'S'/ P CONST. 'i/ L 1J
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY L
C STATE MAJOR SECOND LOCA
NL� (CIRCLE)
NO. OF BLDG S.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL 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 I �� f , 1 0
permit is issued,I shall not employ any person in any manner OWNER /a 29a, ='
so as to become subject to the Workers'Compensation Laws. MAIL _ OCCUPANCY GROUP
J����� O
�!� U
Date Applicant ADDRESS
/� Lal
NOTICE TO APPLICANT: If, after making this Certificate of CITYj/�� TEL. OCCUPANT LOAD o_
Exemption, you should become subject to the Workers' �/ No. _3 7
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 GEOLOGY INSPECTION El
❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter I 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 ander L _ � r
effect. SPACESG R6q D PROVIDED
License Number Lic. Class
r LIMITED TIME USE
I
Contractor Date �� � C DATE DATE
' FROM: TO:1.,f
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF No. of / 4Te3 INSPEC •s
acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES / SIGNA E
iness and Professions Code). FINAL APPROVAL ?��-` I
PRESENT USE OF BUILDING -
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION No OF EXISTING BUILDINGS
ON LOT AND USE VIOTA� o 00
I hereby affirm that I am exempt from the Contractor's CASH 83.00
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED �H"A' 3E nP�ICi
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
111000-0001 10/ 1/913
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency I L ��� ,
for the performance of the work for which this permit is i
issued(Sec.3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCG.
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 3
ordinances and State laws relating to building construction,
and here y authorize representatives of this County to enter TOTAL FEE
uv
th above-mentio d pepty,%.fr inspection purpose,`V j1 SEE REVERSE FOR EXPLANATORY LANGUAGE
04
`� lJ
Signature of Permittee Date