HomeMy Public PortalAbout4932 WILLMONTE AVE_Miscellaneous__ WOTtICERS'COMPENSATIONDECLARATION CE8754(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.certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.). .
Policy No. Company FOR APPLICANTTO.FILLIN BUILDING Q ! J
'U'LD S
Certified copy is hereby furnished. BUILDING �J�2 !G P LOCALITY, Q
ADDRESS v
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.1 _.J La,.4.,4� IU
Date Applicant NEAREST DISTRICT No. GROUP TYPE O E3 D BY
CROSS ST. (� /"C �y:q 1. O _a CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' L6 GAL J
COMPENSATION INSURANCE DfiscRlPrioN ' LOT NO. BLOCK mar HIGHWAY STATS MAJOR SECOND LOCAL
NO. �(��• (CIRCLE)
NO. OF HLOGS.
(This section need not be completed if the work involved TRACT <jO NOW ON LOT c. USE ZONE SPE IAL CONDITIONS
by the permit is for'one hundred dollars ($100)'or less.)
USE of C_- ' C/
SIZE OF LOT �b � EXISTING BLDG./
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 ,�.' p p/ 0 y
so as to become subject to the.Workers' Compensation Laws. IL. l OCCUPANCY GR06P /� C3
ADDRESS ;Z !� r' e rl� '
Date /— R Applicant 0 f 22Z�-i�
NOTICE TO'APPLICANT: If,after making this Certificate of CITY NOL. 6 D r OCCUPANT LOAD y
Exemption, you,should become subject to the Workers' APPLICATI N 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 N ❑
deemed revoked. ❑ ❑ o'Spec. Knowl.
EJLICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Device's
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
mess and Professions Code,and my license is in full force and
effect{ PARKING REq•D O PROVIDED D
SPACES
License Number Lic.'Class I. LIMITED'TIME USE
Contractor Date DATE DATB
I am exempt from the licensing requirements as I am a 'FROM: 707
licensed -architect or a registered professional engineer SIZE OF_ / 7 Q NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus EXISTING BLDG.G. /V6�' STORIES / SI NATURE
iness and Professions Code).
Lic.or Reg.No. • Date PRESENT'USE OF BUILDING L, $�/ d�/%V e-9 , FINAL APPROVAL
HOME OWNER-BUILDER DECLARATION 'No. OF EXISTING BUILDINGS ,pp :I•,
ON LOT AND Ue
SE (�/v
I hereby affirm that I am exempt from the 'Contractor's
License Law for the following reason.(Section 7031.5, Busi- ; i,;,_sib
nes's d Professions Code): NO. PARKING -
I, as owner of the property, will do the work and the SPACES PROVIDED (' (�
structure is not intended or offered for sale (Section
;Bp 1
O
7044,Business and Professions Code). � `. �_
°—
CONSTRUCTION LENDING AGENCY PROPOSED USW OF BUILDING 1\ S! / ell C . ' r•4r;_` ', •�',. C>i(-c�:i
I hereby affirm that there is a construction lending agency
��
s,I-;
for the performance of the work for which this permit is -
issued(Sec.3097,Civ.Q.
Lender's Name ^:..�,.;, e; • rc
PROPOSED MAX.-OCC. y
Lender's Address i , 1 _
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
ordinances and State laws relating to building construction,
and hereby authorize'representatives•of this County to enter TOTAL FEE
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date