HomeMy Public PortalAbout4850 WILLMONTE AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION
I hereby affirm Oat'I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, ur a ce;tificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.Q.
Policy+No, Company FOR APPLICANT TO FILL IN ADILDI'1
DRESS
Certified copy is hereby furnished. BUILDING W.IZ1l��1Va /1�A LOCALITY L /
AD DR LTSS s���2t -.G4
Certified copy is filed with the county building inspection LOCALITY NIrAREST
department. �,u�/ �� ,�� :�!�)�r1i CROSS ST.
Date Applicant NCAREST �t �� DISTRICT NO.TG OUP TYPE P CE SSED BY
CROSS ST. ny CONST. i
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �!/L
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
NO. (CIRCI.D) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(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
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. it
C7
permit is issued,I shall not employ any person in any manner OWNER pSSL,�1
so as to become subject to the Workers' Compensation Laws. MAIL r OCCUPANCY GROUP
DDRY l�� war'///"'tlfjV`C f1 b'� v
Date AESS
Applicant uJ
NOTICE TO APPLICANT: If, after making this Certificate of CITY y �;y NOTIE.9I/g OCCUPANT LOAD
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 or this permit shall be TRAILER USE GEOLOGY 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 L
effect. �' 'LR PARKING SPACES REO'D PROVIDED
License Number Lic. Class O �.-/ / LIMITED TIME USE
Contractor Date �D. �'�� DATe DATA
r/
❑ I am exempt from the licensing requirements as I am a / / FROM: TO:
licensed architect or a registered professional engineer SIZE OFNO.OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES ../// SI NATURE
iness and Professions Code). /l FINAL APPROVAL
Lic.or Reg.No. Date
PRESENT USE OF BUILDING � �'—f� J 7
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS �I�- I,Q
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 and Professions Code): NO. PARKING
SPACES PROVIDED �
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). �-t`_ t -'
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ' -[-���� ,� f C(•jW
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.Q.
Lender's Name '
PROPOSED MAX. OCC. �=•�J i
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 Z j(,.�4D
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE -:%5}G
upon the above-mentioned pjoperty for inspection purposes.
17A SEE REVERSE FOR EXPLANATORY LANGUAGE
ILyL.I
Signature of Permittee Date