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Home My Public Portal About4947 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 a certified copy thereof(Sec.3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING D ADRESS 7 Certified copy is hereby furnished. BUILDINGLOCALITY 03 ADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEARESTGd� DISTRICT NO. CC��AAAQQQ UP TYPE PRO SSED BY CROSS ST. r aF 2 CON CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 19 p J COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY No.�(��-� (CIRCLE) STATE MAJOR SECOND LOCAL Q NO. OF BLOGS. (This Section need not be completed if the work involved TRACT 17c (J 1A,16/ NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit Is for one hundred dollars ($IOO) OI ICSS.) SIZE OF LOT ,5�.x / !�� EXISTINGUSE OF BLDG. I certify that in the performance of the work for which this CD permit is issued,I shall not employo any person in any manner J ,1 so as to become subject to the orkers' Compensation Laws. owNER �/G��(J, �/ �•t`r�S� ( v � OCCUPANCY GROUP EE3] � A.A.R ESS �[ / !� Y1R�'� V Date Applicant TE L. S 7f y' g7 OCCUPANT LOAD D` NOTICE TO APPLICANT: If,after making this Certificate of CITYLSIIA� L_ NO. �/� z Exemption, you should become subject to the Workers' LIGATION FOR �/� �O/—�Z3 IT HARDWARE: Compensation provisions of the Labor Code,you must forth- ❑ 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 effect. �' PARKING RSQ'D PROVIDED AW Nee it SPACES J License Number Lic. Class /�(f/, I Jr LIMITED TIME USE 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 INSP CTOR•3 acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG CTURE iness and Professions Code). 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 and Professions Code): NO. PARKING 0 1, 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). ;2 6 0 Q 4 A CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING # DD0D30 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is I o o 8 Q 5 0 issued(Sec.3097,Civ.Q. Lender's Name 0 0 08 Q 5 Q V PROPOSED MAX. OCG. Lender's Address 1 1.21 -86 1 certify that I have read this application and state that the PERMIT FEE 9, G D above information is correct.I agree to comply with all County ISSUANCE FEE _sD ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE u on lie above-men 'bn ropert or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE la SyOato of Permittee Date D 4? I w tIKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION I I CE 875 I t( eby—affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Iu' insure, o a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy Do. Company FOR APPLICANT TO FILL IN BUILDING V7 A ADDRESS ❑ Certified copy is hereby furnished. BUILDING // I.Q t/�/+ LOCALITY ❑ ADDRESS ZJ-,4 A G Certified copy is filed with the county building inspection-_ n NEAREST /' LOCALIT9�—/_ .�M CROSS ST. L i�I Date Applicant NEAREST //I� DISTRICT NO. GR P CYPE ONS ROC SSED Bx CROSS ST. !�-�� Z- !7 /- CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL S, orl IT COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP N0. (C�C HIGHWAV NOE) STATE MAJOR SECOND LOCAL >" . OF BLDGS. tl (This Section need not be completed if the work involved TRACT NOW ON LOT USF- ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE OF I V SIZE OF LOT EXISTING BLDG. cr I certify that in the performance of the work for which this a�� O permit is issued, I shall not employ any person in any manner OWNER �,e,� / H so as to become subject to the Workers'Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS `,I 7-r/—F— C W Date Applicant n" TEL. Cn NOTICE TO APPLICANT: If, after making this Certificate o!!1— CITY NO. OCCUPANT LOAD z Exemption, you should become subject to the WorkersAPPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions Or this permit shall be TRAILER USE GEOLOGY INSPECTION C] 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 q (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 effect. PARKING REQ'D O PROVIDED D SPACES License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE FROM: TO: ❑ I am exempt from the licensing requirements as I am II 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). PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date ' NO.OF EXISTING BUILDINGS �� HOME OWNER-BUILDER DECLARATION ON LOT AND USE �/J I hereby affirm that- I am exempt from the Contractors �(/' 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). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 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.). /� `{ Lender's Name PROPOSED MAX. OCC. 1-7 o , Lender's Address PERMIT FEE r I certify that I have read this application and state that the ISSUANCE FEE above information is correct.I agree to comply with all County 0 —er finances and State la eating to building onstruction, TOTAL FEE and ereby authori rise tatives of this C my to enterja Up the abpve- tia ed r perty f r ' s cti n purposes. E REVERSE FOR EXPLANATORY LANGUAGE ignature of Date r