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HomeMy Public PortalAbout5020 ENCINITA AVE_Miscellaneous__ WOR KE R S'COMPENSATION DECLARATION CE 875(11-84) MISCELLANEOUS APPLICATION 'r 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.). BUILDING �- Policy No. Company FOR APPLICANT TO FILL IN ADDRESS ne Certified copy is hereby furnished. BUILDING Oil 1 i XX ADDRESS 1 LOCALITY , W Certified copy is filed with the county building inspection LOCALITY NEAREST Lo department. 3M CROss ST. r �„u - Date Applicant NEAREST DISTRICT NO. GROUP TYPE LW I ESSED BY CROSS ST. � CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL tom' COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY .0. (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 A. I certify that in the performance of the work for which this sizE of Lors®�j EXISTING BLDG. VJ 0 permit is issued, I shall not employ any person in any manneXX OWNER of building 44L'i 1 )10/) so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS ' 1 .p//� C U Date Applicant w NOTICE TO APPLICANT: If, after making this Certificate of CIT NO. 6_)y_99 OCCUPANT LOAD V3 Exemption, you should become subject to the Workers' — Compensation provisions of the Labor Code, you must forth- 7APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 1 hereby affirm that I am licensed under provisions of Chapter i SAFETY PERMIT E] (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 an X effect. IQ3IIle of businNe� ess PARKING REQ' � PROVIDED 9 I SPACES License Number Lic. Class C,I ,�y}`��`` LIMITED TIM -r Contractor Date © V •U E GATE GATE � (.�� •� G� PRO.: TO: El I am exempt from the licensing requirements as I am a l�/r / a VVV licensed architect or a registered professional engineer SIZE of NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES / SIGNATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL 7,y� Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND_USE O1 I hereby affirm that I am exempt from the Contractor's tj�? License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED as owner of tiie property, will do the work and the structure is not intended or offered for sale (Section 044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I 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.). 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 25 .00 upon tIleAove-inentionedqroperty for inspection purposes. i, XX XXg--��-9� SEE--) EE REVERSE FOR EXPLANATORY LANGUAGE 17 Si ature of Permittee Date