HomeMy Public PortalAbout5233 WILLMONTE AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
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I hereby a ethat I have a certificate of consent tCE 875(11-84) M ISCELLANEOUS APPLICATION
self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION L1
insure'or a certificate
ificate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
ADDRESS ✓
Certified copy is hereby furnished. BUILDESSING S a 3 l LCHO�vr,c� LOCALITY
A.
0 Certified copy is filed with the county building inspection LOCALITY ��I��L� C�.j NEAREST OF Or
department. CROSS ST.
Date Applicant NEAREST ,J) DISTRICT GROUP ITYPE P ESSED BY
CROSS ST. ��¢L:O L(!t/r/ �!/�� �.v - CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCKNIA' HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL 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 I.OT75 X O S' EXISTING BLDG. �_ 1-1,7 �j �-� >-
o_
permit is issued,I shall not employ any person in any manner OWNER � o
J
so as to become subject to the Workers' Compensation Laws. MAIL r OCCUPANCY GROUP
Ja
Date A licant ADDRESS � 1_
w14 ~Ajr4 L�iJ
PP `
NOTICE TO APPLICANT: If,after making this Certificate of aIT r r No��� � ! OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION 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 ❑
deemed revoked. ❑ ❑ No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT F] (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 COA/tIE21�D C_LoSET D �� .OTy
effect. PARKINGREq'D D PROVIDED
SPACES J
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
0 I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO.OF PROM• To. INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI TURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING FINAL
Lie.or Reg.No. Date V_I
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS --
ON LOT AND USE
I a a
I hereby affirm that I am exempt from the Contractor's A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
SPACES PROVIDED "T-In1l:
El I, as owner of the property, will do the work and the i i 1 C.�=
structure is not intended or offered for sale (Section -s"I iii '6 - ,� __r
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING ; .)=_;': -
I hereby affirm that there is a construction lendingagency -'j-; •�;:'� 1;=1
:.• �i• 3� �_
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name -
s
PROPOSED MAX. OCC. 11lJIJIJiJ•,-
Lender's Address -- -
PERMIT FEE 30 ,A'O J•=�C"+-�� � 3'!r •�-_�
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,
an reby authorize representatives of this County to enter TOTAL.FEE
o he above-men ' ned roperty for inspection purposes.
�6 � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee D to