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Home My Public Portal About4917 ENCINITA AVE_Miscellaneous__ RS'COMPENSATION DECLARATION CE 875(2 80) MISCELLANEOUS APPLICATION I he that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) - Pollcy No Company FOR APPLICANT TO FILL IN BUILDING ^� ADDRESS / Certified copy is hereby furnished BUILDING LOCALITY ElADDRESS Certified copy is filed with the county building inspection LOCALITY NEAREST department CROSS ST � Date ApplicantAREST DISTRICT NO GROUP TY / PRO ED BY ' CROSS ST 5'�^ CONST L/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ( VVV COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SECO D LOCAL O_NO OF BLDGS O (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE FCIAL CONDITIONS U by the permit is for one hundred dollars ($100) or less) USE OF SIZE OF LOT EXISTING BLDG / I certify that in the performance of the work for which this 0 permit Is issued, I shall not employ any person In any manner OWNEw U so as to become subject to the Workers' Compensation Laws IL .) //{i P nT OCCUPANCY GROUP I /� w ' AD ESS C N fi� I V v - a Date Applicant N NOTICE TO APPLICANT If, after making this Certificate of CITY NO OCCUPANT LOAD TE Z Exemption, you should become subject to. the Workers' APPLI ATION 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 I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) No of EXITS 9 (commencing with Section 7000) of Division 3 of the Busi ness and Professions Code, and my license is in full force,and PARKING effect SPACES REO'D O PROVIDED License Number Lic Class LIMITED TIME USE , Contractor Date DATE DATE ❑ FROM TO I am exempt from the licensing a requirements as I am licensed architect or a registered professional engineer SIZE OF No OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXI ING BLDG STORIES NATURE (ness and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Lic or Reg No Date (fJ go No of EXISTING BUILDINGS HOME OWNER BUILDER DECLARATION ON'LOT AND USE �yIy�3 6 8`55p ARO I hereby affirm that I am exempt from the Contractor's tl • • • • i i License Law for the following reason (Section 7031 5, Busi- J 219-85 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 Ce ®V` D I hereby affirm that .there is 'a construLtion lending agency I for the performance of the work for which this permit is Issued (Sec 3097,Civ C) ^ V Lender's Name PROPOSED MAX OCC Lender's Address PERMIT FEET 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 iereby authoriser ntatives of this County to enter TOTAL FEE n the above do a rop rty for In a ion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Jg ature of rmitt a I Date WOR KEFS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION !� CE 875(11-84) r I I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION dull insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec 3800,Lab C) Policy No Company FOAPPLI T TO FILL IN, BUILDING R ADDRESS Certified copy is hereby furnishedUILDING LOCALITY ADDRESS ECertified copy is filed with the county building inspection CALITY NEAREST department CROSS,;T Date Applicant NEAREST f DISTRICT NO GROUP TYPE PROCESSED BY CROSS ST CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 4 COMPENSATION INSURANCE DESCRIPTIONLor No BLOCK MAP HIGHWAY rvO (CIRCLE) STATE MAJOR SECOND LOCAL NO OF S (This section need not be completed If the work Involved TRACT NOW ON LOTUSE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE OF SIZE OF LOT EXISTING BLDG I certify that in the performance of the work for which this C:) permit is issued, I shall not employ any person in any manner OWNER s� so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP o ADDRESS F--' Date Applicant Tp' LV NOTICE TO APPLICANT If, after making this Certificate of CITY NEo 0 �{ U OCCUPANT LOAD Exemption, you should become subject to the Workers' z APPLICA ION 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 ❑ 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 L4 e PARKING REQ'D PROVIDED SPACES License Number Lie Class 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 INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Q/9 Lie or Reg No Date HOME OWNER-BUILDER DECLARATION NO OF ExlsTi BUILDINGS' FEE I hereby affirm that I am exempt from the Contractor's ON LOT AND License Law for the following reason (Section 7031 5, Busi- ness usi ness and Professions Code) NO PARKING I, as owner of the property, will do the work and the SPACES PROVIDED 51322 AM a:L15 structure is not intended or offered for sale (Section 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE: 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 C) Lender's Name PROPOSED MAX OCC 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 ordinances and State laws relating to bu ding construction, and hereby authorize repre ntatives this County to enter TOTAL FEE po the above-me ed operty or ins on purposes 1� � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o ermittee Date