HomeMy Public PortalAbout4921 ENCINITA AVE_Miscellaneous__ WOP,i> ERS'COMPENSATION DECLARATION
CE 875 0 1 84) M I SC E L LA N EO U S APPLICATION
CE 875
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 APPLICANT TO FILL IN ABUILDING / `
o� ��{{}}-- �) � DDRESS Q!
Certified copy is hereby furnished pDPRE35 rc m� VC) A kv \ LO CA LIT
0 Certified copy is filed with the county building inspection OCALITY ` NEAREST
department /�� CI CROSS Sr
Date Applicant N REST ' DISTRICT NO GROUP TYPE P OC SSE&BY
ROSS ST A �Q , Q CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (D /�~
COMPENSATION INSURANCE DESCRIPTION I LOT NOO�L- )ib BLOCK MAP HIGHWAY
NO
NO (CIRCLE) STATE MAJOR SECOND LO L
(This section need not be completed if the work involved TRACT NOWOF BLDGS ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) USE OF I
SIZE OF LOT EXISTING BLDG d/ -- ��
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner ER r.� U 1 AN K
so as to become subject to the Workers' Compensation Laws AIL W OCCUPANCY GROUP C)
ADDRESS
Date Applicant t)Ci 0 �v� -
NOTICE TO APPLICANT If, after making this Certificate of cirY Tey �� (�7 NoL OCCUPANT LOAD °
Exemption, you should become subject to the Workers' A LIGATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions oI this permit shall be TRAILER USEGEOLOGY INSPECTION El
revoked E] ❑ No Spec Knowl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT
9 (commencing with Section 7000) of Division 3 of the Busr EJ (LIST ITEMS BELOW) NO OF EXITS
ness and Professions Code, and my license is,m full force and
effect PARKINSPACES G REQ D L� PROVIDED
"
License Number Lic Class '" LIMITED TIME USE
Contractor Date DATE DATE
0 I am exempt from the licensing requirements as I am a FROM TO
licensed architect or a registered professional engineer SIZE OF NO OF INS ECTOR S
'acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES GNATURE
mess and Professions Code) USE OF BUILDING FINAL APPROVAL /7
Lic or Reg No Data ESENT D G�
S70 c-
HOME OWNER-BUILDER DECLARATION NO OF EXISTING UILDINGS
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
DI, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section ;2 5 2 8,7 A
7044,Business and Professions Code) /1 # o o • e $8
CONSTRUCTION LENDING AGENCY POSED USE of BUILDING
/� '0 0 0 0 . 0 0
I hereby affirm that there is a construction lending agency 6 t« A W S7n&-A A&D _ 1 i
for the performance of the work for which this permit is �/
issued(Sec 3097,Civ C) W 0 x 2 1 8 6
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 building construction,
and hereby authorize repraentatives of this County to enter TOTAL. FEE
upon the menti rope or inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
gn ure off Permittee '7X 7 D to