HomeMy Public PortalAbout4937 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 876(1 1 84) X11�.JC� I�w, EO U� APPLICATION
I hereby affirm that I have a certificate of consent to self
insure or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION u
a certified copy thereof(Sec 3800,Lab C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnishedILDIN
ADDRESSG 4937 ENCINITA AVE LOCALITY
DCertified copy is filed with the county building inspection OCALITY r1Tf2�JPLE CITYNRoss NEA11 REST
Date Applicant NEAREST DISTRICT NOGR UP TYPE R ESSED BY
CROSS ST ' CONST 'L I
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY
rvo (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
SIZE OF LOT EXISTING BLDG / d
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner owNE o
so as to become subject to the Workers' Compensation Laws MAIL KAZ OCCUPANCY GROUP 2�1
ADDRESS
Date C-3
Applicant L
NOTICE TO APPLICANT If, after making this Certificate of CITY TNOLLu OCCUPANT LOAD n
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
deemed revoked TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec Knowl El
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 D PROVIDED D
SPACES
License Number Lic 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 TN. OF INSPECTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE
mess and Professions Code) FINAL APPROVAL /,/]�
PRESENT USE OF BUILDING
Lic or Reg No Date {p
OFFICE & STORAGE
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS D,
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- (/ !II-1130-113131 5/ -_/:L
ness and Professions Code)
0 I, as owner of the property, will do the work and the NO
Aces PROVIDED Sc IS 5 30
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 OFFICE & STORAGE
for the performance of the work for wluch 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 building construction,
and hereby authorize represent Ives of this County to enter TOTAL FEE Qn
up above-mentioned pr trt for inspection p po s
f G / SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee atdf