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HomeMy Public PortalAbout4943 WILLMONTE AVE_Miscellaneous__ ,`, +ORKE)IS'COMPENSATION DECLARATION 76M444 I, CE 875(11-84) M ISCELLANEOUS APPLICATION I lrcreby affirm t1*1 I hive a certificate of consent to self COUNTY OF LOS ANGELES 'BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insuiance,or a certified qopy thereof(Sec:3800,Lab.C.). Policy No. CompanADDRESS _1 W 1y FOR APPLICANT TO FI LL IN BUILDING -1Q 1- p, 11 Certified copy is hereby furnished. noca'ss %JiA'twvn& LOCALITY 14 Ct y❑ Certified copy is filed with the-county building inspection LOCALITY.r 1 NEAREST department. l CROSS Sr. -1AJ 1A Date Applicant NEAREST DISTRICT NO, GROUP TYPE PRZZ ED BY CROSS ST: i(/j ^ CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 5.ub ROU COMPENSATION INSURANCE DESCRIPTION BLOCK MAP HIGHWAY STATE MAJOR SEG D LOCAL NO. . (CIRCLE) 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 ' SIZE OF LOT IL© EXISTING SI G. ' I certify that in the performance of the work for which thisI e permit is issued,I shall not employ any person in any manner OWNER =� so as to become subject to the Workers' Compensation Laws. : !OCCUPANCY GROUP Date Applicant ADDRESS Lf�Lf 3 � jytdyr, e w TEL. �g L/l�L/ OCCUPANT LOAD y NOTICE TO APPLICANT: If,after making this Certificate of c1rY $yl, No — 7 0o Z Exemption, you should become subject to the Workers', APPLIC ION FOR EXIT HARDWARE: _ Compensation provisions of the Labor Code,you must.forth- with comply With such provisions oI 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 ° effect. 1 PARKING REQ'D PROVIDED � SPACES License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE � I am exempt from the licensing requirements as I am a / O FROM: TO:. licensed architect or a registered professional engineer INSPECTOR'S SAG`a•.••Nr_a. SIG TUR acting in my professional capacity (Section 7051, Bus- ® �._ iness and Professions Code). 1 '" '�I FINAL APPROVAL /'//�.0 ,..• ° ✓ Lic.or Reg.No. Data HOME OWNER-BUILDER DECLARATION Ivo. of Edi r�i rNo-BwrD+fvo3 :ice( ON LOT nNe lav i I hereby affirm that I am exempt from the Contractor'sU`- License Law for the following reason (Section 7031.5, Busi- 'I: n, Ztz ness and Professions Code): NO. PARKING � s S _ •: .TTEI�,. I, as owner of the property, will do the work and the SPACES PROVIDED I •TTE"1* ,* structure is not intended or offered for sale (Section 7044,Business and Professions Code). TOTAL 2ZZ 1-9 75 D PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY CHL.`.it j i. r'e I hereby affirm that there is a construction lending agency. . / -� for the performance of the work for which this permit is _ - assued(Sec.3097,Civ.Q. Lender's Name ' PROPOSED MAX. OCC. 4 0CLG--1.ice 121131 G ! :� Lender's Address PERMIT FEE � Jr- C)O 4c, " i -.11 `F=_'� 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.FEE uponthe property for inspection purposes. :breg-mentioned ,,'' , � . Z-- SEE REVERSE FOR EXPLANATORY LANGUAGE )�_ Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm at 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 a certified copy thereof(Sec.3800,Lab.C.). Policy No. Crompany FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDESS (/�ING 4 All LOCALITY Pa / DCertified copy is filed with the county building inspection LOCALITY /��/`) NEAREST department. Q`� CR oss ST. Date Applicant NEAREST DISTRICT NO. GROUP TYP CESSED BY CROSS ST. -l—O/ P ;9 CO 7. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Q COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NOOF BLDGS. NO. (CIRCLC) . (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIOFf3 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 ZZZAAl LA y /4 permit is issued,I shall not employ any person in any manner OWNER L so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ( J z ADDRESS `� O Date Applicant TEL. IJ 1 NOTICE TO APPLICANT: If, after making this Certificate of CITY' NO. / po Z OCCUPANT LOAD N Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code,you must forth- APPLI TION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ i. 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- ness and Professions Code,and my license is in full force and ARKING effect. - SPACES REq'D —PROVIDEO� C License Number Lic. Class LIMITED TIME -7, —_ _ 471 DATE! GATE Contractor Date =�� , ° -�% � F ' I rG_ Sl:- 0 1 am exempt from the licensing requirements as I am a �� �- PROMO TO' CAAHI ° 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). l)i+'�I`-`•tii;' % ''' '=r FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date -- 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 usiness and 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 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED OF BUILDING 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. Lender's Address I certify that 1 have read this application and state that the PERMIT FEE age ,es- above information is correct.I agree to comply with all County ISSUANCE FEE .0lo.yr ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE Agllvir upon za�brty for inspection purposes. g SEE REVERSE FOR EXPLANATORY LANGUAGE s. �i. Signature of Permittee Date