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Home My Public Portal About4930 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 y, CE 875 (11-84) MIS CELLAr-,E(. US APPLICATION I''hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION + insure, ct a certificate of Workers'Compensation Insurance,or �a certifiedcopy thereof(Sec. 3800,Lab.C.). Policy No. NWC4 20(r GULDEN EAGLE INE FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. auILDING LOCALITY T XX ADDRESS LLL--- FCertified copy is filed with the county building inspection LOCALITY TEMPLE CITY , CA. 91780 NEAR sT. department. XX Date Applicant NEAREST DISTRI T NO. GROUP TYPE CESSED BY CROSS ST. LOWER AZUSA RD . p� CONST.// CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL { JL COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (This section need not be completed If the work involved TRACT NOW ON LOT USE ZONE SPECIAL 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 slzE OF LOT EXISTING BLDG. >- permit is issued, 1 shall not employ any person in any manneXXo f building C . K. K E E B L E c_ OWNER ® C-3 so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP "- ADDRESS77457 MICHIGAN DR. Date Applicant L NOTICE TO APPLICANT: If, after making this certificate of .,,PALM DESERT , CA TNtL19—3 60—7 7 6 4 OCCUPANT LOAD v3 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 S TRAILER USE E] GEOLOGY INSPECTION No Spec. Knowl. m1 dee ed revoked. LICENSED CONTRACTORS DECLARATION I OCCUPANCY INSPECTION Panic Devices El I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT A❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- I NO. OF EXITS ness and Professions Code, and my license is in full force anix IN effect. ame of business PARKING REO`D � PROVIDED JJ License Number Lic. Class i WESTREP ENTERPRISES SPACES 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 SIZC OF NO. OF INSPECTOR S g g EXISTING BLDG. STORIES 1 SIG ATURE acting in my professional capacity (Section 7051, Bus- 5600 iness and Professions Code). PRESENT USE OF BUILDING -- -- FINAL APPROVAL Lie.or Reg.No. Date VACANT kJ HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS (t�I ON LOT AND USE I hereby affirm that 1 ani exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 6 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). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDINGOFFICE & DISPLAY 1 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.). ",: •`;:-_; !=.t Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that 1 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 hereby authorize representatives of this County to enter TOTAL FEE 25-00 upon the above-mentioned pr p t forjQpection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE XXL", XX�,-/Ca Signaturc of P nnittec Date WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION CE 875 (11-84) r ' I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION 7ILJ'� insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN BUILDING /� /��//////f` ADDRESS 0 ///9L� ` Certified copy is hereby furnished. BUILDING ADDRESS LOCALITY Certified copy is filed with the county building inspection L pLI ' NEAREST department. �, CROSS ST. Date ApplicantNEAREST DISTRICT NO. GROUP TYPE RESSED BIY CROSS ST. r^�� 40 CONSTO, CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK (CIRCLE )rvO.` +Z�YJ (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL 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 LOT EXISTING BLDG. �, a permit is issued, I shall not employ any person in any manner izOw o so as to become subject to the Workers' Compensation Laws. AIL �,�/^J� OCCUPANCY GROUP —Z� AD RESS� ��C.1�i 1- Date Applicant ly TEL' OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY 7 No. Exemption, you should become subject to the Workers' APP 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 O No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El 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 REQ'D PROVIDED SPACES License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE El I am exempt from the licensing requirements as I am a FROM TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG /00 STORIES SINATURE iness t Reg.No. Date d Professions Code). �� Lie.or Reg. INAL APPROVAL g PRESENT USE OF BUILDING / 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 ElI, as owner of the property, will do the work and the SPACES PROVIDED � A 5 8 7,:7 A structure is not intended or offered for sale (Section }� 7044,Business and Professions Code). # • ° • • 88 CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING /(/�0 o • 0 0 0 0 • • z I hereby affirm that there is a construction lending agency 6c-")�64 for the performance of the work for which this permit is `1 1 1.05t86 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 building construction, and hereb authorize representatives of this County to enter TOTAL. FEE upon the b ve-menti ed pr erty for inspection purpo S. J� EE REVERSE FOR EXPLANATORY LANGUAGE Sigq5iZe of Permittee Date