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Home My Public Portal About5001 ENCINITA AVE_Miscellaneous__ J WORKERS'COMPENSATION DFCLARA,TION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure, or a certificate of Workee rs'Compensation Insurance,or a certified copy thereof(See 3800,Lab C) 'Policy No Company FOR APPLICANT TO FILL BUILDING ADDRESS Certified copy is hereby furnishedBUDRILDESING 001 ENCI LOCALITY ADS ElCertified copy is filed with the county building inspection LOCALITY NEAREST department CROSS ST Date Applicant NEAREST LOW DISTRICT NO GROUP TYPE PROCESSED BY x CROSS ST CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SECOND LOCAL NO OF LDG$ (This section need not be completed if the work Involved TRACT NOW ONBLOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) USE OF �- Icertify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG o permit is Issued, I shall not employ any person in any manner OWNER y SCHRUDDER so as to become subject to the Workers' Compensation Laws MAIL OCCUPANCY GROUP ADDRESS 5001 ENCINITAS cis Date C�''o Applicant NOTICE TO APPLICANT If, after making this Certificate of CITY TEMPLE CITY L 8 818-28 OCCUPANT LOAD n Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Z Compensation provisions of the Labor Code, you must forth- with comply with such provisions oI 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 A/1� D� 5 �� effect M PARKING REQ D � PROVIDED License Number LIc Class "SCHRUDDE " SPACES LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO OF FROM TO In" PE CTOR�s acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES sI NATURE mess and Professions Code) FINAL APPROVAL In PRESENT USE OF BUILDING Lic or Reg No Date DOG KENIN—ET BOARDING GROOMING 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 followmg 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 7 513 1 PM 051 structure is not intended or offered for sale (Section 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDINGDOG KENNEL BOARDING I hereby affirm that there is a construction lending agency GROOMING BREEDING TRAINING - CATTERY. O 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 PERMIT FEE 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 hereby authorize representatives of this County to enter TOTAL FEE up n Z bove-mentioned op y for inspect n purposes /D SEE REVERSE FOR EXPLANATORY LANGUAGE lgnatur of Permittee e �� !b%Ay�911' KERS'COMPENSATION DECLARATIONCE 875 (2 80) -MISCELLANEOUS APPLICATIONCE 875 affirm that I have a certificate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION- / or a certificate of Workers'Compensation Insurance,or /irtified copy thereof(Sec 3800,Lab C) /icy No Company FOR APPLICANT TO FILL IN BUILDING D _ f-/'- ADDRESS C1 Certified copy is hereby furnished UILDING C` LOCALITY ADDRESSI JI-14 500 1 ❑ Certified copy is filed with the county building Inspection / ^ . ' NEAREST department Lo ALITY �CYV� �/ /. �I' CROSS ST Date Applicant EAREST G� \ CCw `J T q DISTRICT O G UP TYPE PRO SED BY 3CROSS ST ' w`a Z Ja' CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �� HIGHWAY COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK NOF (CIRCLE) STATE MAJOR SECOND CAL d This section need not be completed ithe work involved No of BLDGs ( ldfh p TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O by the permit is for,one hundred dollars (5100) or less) USE OF SIZE OF LOT EXISTING BLDG .� t I certify that In the performance of the work for which this0 permit Is Issued, I shall not employ any person in any manner OWNER O ri1�P� H so as to become subject to the Workers' Compensation Laws AIL OCCUPANCY GROUP W ADDRESS 5� t lA - tl Date Applicant Z 'r TEL 33�—C(/p OCCUPANT LOAD z NOTICE TO APPLICANT If, after making this Certificate of CITY'F L e C)Li No 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 TRAILER USEE] GEOLOGY INSPECTION No Spec Knowl ❑ deemed revoked OCCUPANCY INSPECTION Panic Devices LICENSED CONTRACTORS DECLARATION ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT i 1 (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 ePARKING effect SPACES REO'D E:= PROVIDED License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE FROM TO ❑ I am exempt from the hLensing requirements as I am a licensed architect or a registered piofessional engineer SIZE OF NO OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXIS ING BLDG STORIES SIGNATURE mess and Professions Code) RESENT USE of BUILDING �i ! FINAL APPROVAL Z / cl Lic or Reg No Date *6 _ , HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE 9 0 O 2 /I I1 I hereby affirm that I am exempt from the Contractor's V LF rt License Law for the following reason (Section 7031 5, Busi- • • • • 8 8 # NO PARKING - ness and Professions Code) SPACES PROVIDED • • O • • O • 2 ❑ I, as owner of the property, will do the work and the structureis not Intended or offered for sale (Section Q 04--; 84 7044, Business and Professions Code) /R.POSED USE OF BUILDING CONSTRUCTION LENDING AGENCY � ; C��'Y1a I hereby affirm that there Is a construction lending agency 1"& CS— for the performance of the work for which this permit Is issued(Sec 3097,Civ C) Lender's Name PROPOSED MAX OCC 3, Lender's Address PERMIT FEE 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, TOTAL FEE and hereby authorize representatives of thisounIy to enter yip th above- enti ed r perty for Ins _tion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permi&We Date