HomeMy Public PortalAbout5024 ENCINITA AVE_Miscellaneous__ •WORKERS"COMPENSATION DECLARATION 76M444
CE 875 (2-80) MISCELLA ,NEOL' APPLICATION
1-hereby affirm,that I have a certificate of consent to self COUNTY OF,LOS ANGELES 4�• 'BUILDING AND.SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy,thereof(Sec 3800,Lab C.) n
Policy No Company FOR APPL'ICANT`TO'F_ILL,IN• y', ADDRESS,'. o�
Certified copy Is hereby furnishedILDING ', LOCALITY ,
❑ thv ADD RE 35 _ fL•• - _ .,
,Certified copy is,flled with e county building inspection
OC ALITY NEAREST
department . ��'! �� CROSS-ST}
Date Applicant EAREST - 'DISTRICT N G OUP TYPE _ PRO D BY
CROSS ST. _ _-� - CONST - ,
CERTIFICATE OF,EXEMPTION FROMiWORKERS' LEGAL J`
s. _ DESCRIPTION LOT NO'•' BLOCK, + Mqp ��—R I�HyyAy }
COMPENSATION INSURANCE w No. , y-W (CIRCLE) STATE MAJOR SECO LOCAL 0."
NO'OF BLDGS. _
(This section need not be completed if the work,involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS 0,
by the permit is for one hundred dollars ($100) or less.) + .
_ USE OF-, /�/�)/�J
�• " - - + SIZE OF LOT` '' EXISTING BLDG. ,N/ I- ' - - • �'•
I certify that in 'the',performance of the work for which this M ILL O',
permit is issued, I;shall not employ any person in any manner OWNER `� '070.,U-
so
L0u F
so as to become subject to the Workers' Compensation LawsAIL_ f OCCUPANCY GROUP a W
Date ->• - } D R E S S=J - _ ` C/3
: a r_
TEL.NOTICE TO APPLICANT If, after making this Certificate of`, CITY NO OCCUPANT LOAD Z
Exemption; -you should become subject to the Workers'
Compensation provisions•of the Labor Code, you must forth; 'APPLICATION,FOR EXIT HARDWARE ,
wlth comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION -•y
-deemed revoked _ ❑ No Spec. Knowl.
dLICENSED CONTRACTORS DECLARATION J OCC?PANCY`INSPEcrION®� ' - = — Panic-Devices
I hereby-affirm that I am licensed under provisions of Chapter ? -.'SA FETY PERMIT q_ (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of the Busi- `
ness.and Professions Code, and my license is in fulf force and PARKING effect
SPACES REO'D PROVIDED
• • - - - -
License Number- Llc Class '
• •, - . - -LIMITED TIME USE
Contradtor Date
'� - ` DATE , •DATE, -
O FROM
I am exempt from-the licensing requirements as I am a
licensed 'architect or a registered professional engineer I SIZE OFY NO OF i INSPECTOR'S
acting In my'professional capacity (Sectiori 7051,"BUs; EXIST NG BLDG. _ . STORIESSIG)tATURE '
mess and Professions Code)
RESENT OF BUILDING
FINAL•_APPROV-AL-
USE
Lic or Reg.No. Date4C-41
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS' b
- ON LOT AND USE - -N • _ -
'A hereby'affirm that I am exempt from the,Contractor's
License Law,for the following reason I(Sectiont7031 5, Busi-
ness and Professions Code) NO PARKING y
SPACES PROVIDED
El1, as owner of the property, will do-the work and the ;': #`•! e • o='$
structure is,not intended or offered for.•sale (Section
7044, Business and Professions Code).. << p
• OPOSED USE OF,BUILDINGi' - -�,'• . Q,'+3,2 6 8-6
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is i 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
PERMLT FEE •�'
'I certify that•I have read this apphcation 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 authorise representatives of this C unty to enter
upo t abovelmentio ed property for msp tion purposes SEE REVERSE FOR`EXPVANATORY LANGUAGE "
Signature of Permittee - Date 7 = J ?