Loading...
HomeMy Public PortalAbout4930 ENCINITA AVE_Building__ WORKERS' COMPENSATION DECLARATION insure,hereby a certithat ficatelhave a of Workers'Colmpensstlonoln consent to o'r APPLICATION FOR BUILDING PERMIT a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.Fy.101-Company BUILDING ❑ Certified copy is hereby furnished. `.L'.Y�CRQWY�I FOR APPLICANT TO FILL IN ADDRESS t3D i Certified copy is filed with the county building inspec- BUILDING tion department. /^►� ADDRESS LOCALITY NEAREST Date ��31�UlSL Applicantt11dDaA S-6-At– CITY ZIP ROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO.�� TEL. SPECIAL I certify that in the performance of the work,for which this OWNER V-aw G,*(V_ NO. CONDITIONS permit is issued, I shall not employ any person in any manner ° DISTRICT GROUP TYPE FIRE PROCESSED BY so as to become subject to the Workers'Compensation Laws. ADDRESS` ��� ( �`o� n/� CONST. ZONE /1 0 Date Applicant ll CITY f ZIP (}!� (lam/� ARCHITECT ORTEL. STATISTICAL CLASSIFICATION APT. NDO. U NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. Exemption, you should become subject to the Workers' CLASS NO. DWELL. UNITS �^�� Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be TEL. / CON ACT R �NO. —/ate BK. PG,(j VALIDATION deemed revoked. �~� LICENSED CONTRACTORS DECLARATION UC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS/ZaNO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. _' $ Lj� �� Professions Code,and my license is in full force and effect. CITY CLASS Vi License Number 35�/ Lic.Class SQ. IZEFT STOROES FO.MILLIIES O EK 2 5.1 7,O A NEW S +�s{ ®,® 0 0 Con DESCRIPTION OF WORK ❑ tF- 2 3 Con ractor Date U , ADD ❑ I am exempt from the licensing requirements as I am a S °FINA ,1 O 5 2 0 licensed architect or a registered professional engineer ALTER ❑ IDAT DATE• acting in my professional capacity (Section 7051, REPAIR ❑ ,o ® 1 0 5 2 ' Business and Professions Code). USE OF DEMOL ❑ F EXISTING BLDG. y 07.31 a86 Lic. or Reg. No. Date APPLICANT TEL. OWNER--BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT ❑ BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT e z 5 4 7,511A the performance of the work for which this permit is issued tInvestigation (Sec. 3097, Civ. C.). # ° ° °•s 8;,J Lender's Name ,1 3 IL 2 5 Lender's Address L.) 4pW Permit Fee 1 m ° a 1 34,25.2 w I certify that I have read this application and state that the Issuance Fee •. ® �V' 9,.1 9-8 6 above information is correct. I agree to comply with all County _ ordinances and State laws relating to building construction, o Total Fee and hereby authorize representatives of this County to enter i•. aup n the above-m ti ed proeerty or inspection purposes. < SEE REVERSE FOR EXPLANATORY LANGUAGE ^ Si a ref plicant or Agent Date ©a // 4lVORKERc �PENSAI!ON DECLARATION ti - e ➢ai`�irm�rhat I have a certificate of consent.to self A P P L I CAT I O N � F O R B U I L D I Workers' Com NG PERMIT n ure, or a certificate of Compensation Insurance, or a certAecy thereof (Sec 3800, Lab: C.) �j COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company I BUILDING Certified copy is hereby furnished. FOR APPLICANT•TO FILL IN ADDRESS U Certified copy is filed with the county building inspec- BU(DING ❑ 493e� ` �C(N('�'A �4VE.. Tion department. ADDRESS -rte Date Applicant CITY �PLE CITY Y ZIP 9 1 7 4 9 0 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' [-SIZE OF LOT 10 �t2 SF NOW ON LOTNO. OF S NDNg NEARESST. COMPENSATION INSURANCE (This'section need not be completed if the permit is for oneTRACT �8 �, ASSESSOR hundred dollars ($100)or less.) BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. USE ZONE MAP OWNER (�IGAQD� jS t1.fEZ`CGlyTREf?�SNo. 287��7t�� �- I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in any manner pp y LI V E�OA.K, SPECIAL ti so as to be co a subject to the Wo ers'Comp e tion L ws. ADDRESS 90 t 4 CONDITIONS �O 2 n CITY TEMPLE CITY zip 911180 oe Dote, r Ap0f 10t� ARCHITECT OR TEL. DISTRICT ['GROUP TYPE FIRE PROC SSED BY NO TO'APPLI ANT: If; alter mq g this Certificate of ENGINEER W�-=�Q P W(L D NO �g 33I-3849 t� CONST.. ZONE Ezem tion, -you should becom�ub'ect to -the Workers' U41/ Compensation provisions of the-Labor Code, you must forth- ADDRESS 19843 PSEPOW LAX (AV LMA `i` with comply with such provisions or this permit shall be N;i 1 TEE' STATISTICAL CLASSIFICATION APT.' NDO. c� deemed revoked. CONTRACTOR 04)N 6. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS," BK PG. "VALIDATION SQ. FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE 589 STORIES FAMILIES ONE VALUATION 2 3.1 2 3 A DESCRIPTION OF WORK NEW Contractor Date ADD ❑ $ # o o-o o 23. ❑ I am exempt under Sec. W�rt�ENt�US1: �VILD�NG ALTERED] , n��a� 1 ° 724,85 B.BP.C. for this reason USE OF REPAIR ❑ E l�a /I/1 Date: EXISTING BLDG. DEMOL ❑ tVv/CVV/ o - 724,8550 Signature APPLICANT WAL7Ee P.WILD N 818 331-3849 FINAL y s (PRINT) { I 1. 1 —85 OWNER-BUILDER DECLARATION ��.p DATE I hereby affirm that I am exempt from the-Contractor's License ADDRESS t98�3 Dr.�ir Vt LWE, �Vt gI?a4 FINAL 0. Law for the following "reason (Section 7031.5, Business and � Professions Code): PRESENT ❑ BUILDING ; I, as owner of the property, or my employees with ADDRESS z 4 2 0. 1 A wages os their sole compensation,will do the work and 000 the structure is not intended or offered for sale(Section LOCALITY _ # c o o o 2 3 7044, Business and Professions Code). MOVING TEL. ❑ ! J ` \ I, as owner of the property, am exclusively contracting CONTRACTOR NO. 1 o O with licensed contractors to construct the project (Sec- 0 ADDRESS '� 0 tion 7044, Business and Professions Code). REQUIREDTOTAL SETBACK FROM CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 0 3 1 1 —8 6 1 hereby affirm that there is a construction lending agency for FRONT S1 46r�� 4 2 0.2 A the performance of the work for which this permit is-issued P.L. ` (Sec. 3097, Civ. C.). SIDE O /q{ 0 0 0 0 0 P.L. .,I .1, 1 6 9.2 Lender's Name " " 1 c N { LDMA'Ref. .5 Lender's Address P.C. Fee$ V Permit Fee I certify that I have read this application and state that the �Ot Issuance Fee Q O LDMA,P/.C,# ! 0 3.1 1 -8".6 . a above information is correct. I agree-to comply with all County Investigation Fee m ordinances and State laws relating to building construction, Total Fee < �[7 �� LDMA Perm. v and hereby authorize representatives of this County to enter Pon the above-mentioned Ay for inspection purpo es. _ ` -q "� /� SEE REVERSE FOR EXPLANATORY LANGUAGE i notureo A licant or A ent Date - - - 40 9 PP 9