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Home My Public Portal About5210 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875(2-80) MISCELLANEOUS APPLICATION : I 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.) Policy No Company FOR APPLICANT TO FILL IN BUILDING Certified copy Is hereby,furnished _ BUILDING LOCALITY +ADDRESS _ Certified'copy is filed with the county building inspection NEAREST department LOCALITYTeMPLE CJ TY CROSS ST - Date Applicant EAREST ,A' ) - DISTRICT NO. ' GROU TYPE` PRO ESSED BY • , .- CROSS ST Ix ER a z usA CONST CERTIFICATE,OF EXEMPTION FROM WORKERS' , LEGAL ti COMPENSATION INSURANCE DESCRIPTION L'f'!, . BLOCK MAP (CIRCLLEE)R ) STATE MAJOR,SECONO LOCAL } NO OF BLDGS No (C - - OL (This section need not.be completed-if'the work,involved TRACT NOW ON LOT USE ZONE' SPECIAL_CONDITIONS r\ ' by the permit is-for one,hundred dollars-($100) or less.) " USE: OF - z U • � 31ZE OF LOT EXISTING BLDG. v - � - 'I certify that,in the performance of the work for which this �; O permit Is Issued, I shall not employ any' person in any,manner OWNEii TE PLE 'CJ *rY S CkOOL DIS�.p+I Icr " (— so as to become subject to the-Workers' Compensatlo_n Laws` ' AIL OCCUPANCY GROUP V ADDRESS . _ -LL Date Applicant. NOTICE TO-APPLICANT If, after'making this'Certificate of CITY Q rTio� 5 OCCUPANT LOAD �_ Exemption, you should become subject to `the Workers'_ e -' APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code,-you must'forih- With'comply with such provisions:or,,this'permit"shall be TRAILER USE❑ GEOLOGY INSPECTION ❑ No Spec. Knowl..❑ deemed_ re-voked,,_,-, LICENSED CONTRACTORS DECLARATION OccUPANCY INSPECTION Panic-Devices 0 , Y( 'I hereby affirm that I am licensed under,provisionsof.Chapter SAFETY PERMIT ❑�� -(LIST ITEMS BELOW) ry0 OF EXITS - 9 (commencing with Section 7000) of Division 3 of the Busi- ne.s and Professions.Code, and my license ism full force-and - ' PARKING. efzect r REO'D O PROVIDED SPACES License Number Lic.Class a LIMITED TIME USE Contractor Date DATE Y DATE • ` - ' FROM TO I am;exempt from the licensing requirements as I am a ' licensed architect or a registered professional engineer SIZE of No OF INSPECTOR'S acting in my professional capacity-(Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE ' Iness-and Professions Code) - FINAL APPROVAL • RESENT USE OF BUILDING YA CAN Lic.or Reg No Date HOME OWNER-BUILDER,DEC LARATION NO OF EXISTING BUILDINGS- R 29 5 7 1,,9,A ON LOT'AND USE _ I ,hereby affirm that I am exempt ,from the Contractor's' #;0 0 o e g g License Law for the following reason.(Sechon 7031 5, Busi-- 'e o 0 0'e o oto ness and Professions Code); _ No PARKING z �• SPACES PROVIDED4 .❑ I, as owner -of the property, will do the,work and the )b 03-83, structure is not intended or offered_for-sale (Section 7044„Business and Professions Code). ; - OPOSE D,U SE OF BUILDING CONSTRUCTION LENDING.AGENCY F hereby affirm that there is a,construction lending agency : J(, 11►I FA '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 siate that the above information is correct I agree to comply with all County !SSUANCE FEE i 'ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize re resentatrves of,'this County to enter upon t e above-me o d proper or inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _ Signature of Permittee J ite�, WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION I hereby affirm that I have certificate of consent to self CE 875 (2-80)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING C".r ❑ ADDRESS wrw•"! '- 'ti. . / '-'" 'f%•;x.`..,,.. -.s._.- Certified copy is hereby furnished. BUILDING ` ADDRESS 'r - Certified copy is filed with the county building inspection LocwLlrY NEAREST •- ,,, department. T y J ceoss ST. Date Applicant L,- NEAREST 1- 3 1 DISTRIC.3 NO. GRO - SED CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NO. BLOCK COMPENSATION INSURANCE MAP HIGHWAY o No. (CIRCLE) STATE MAJOR SECOND LOCAL (This section need not be completed if the work involved NO. cO BLDGS. USE ZONE SPECIAL CONDITIONS P TRACT NOW ON LOT by the permit is for one hundred dollars ($100) or less.) W USE OF .,I SIZE OF Xf ,• I certify that in the performance of the work for which this LOT EISTING BLDG._- F permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. 4 MAILOCCUPANCY GROUP �`.-- � ccADDRESS / .. Q Date Applicant cc TEL. OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of �' clTr No. � p, Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- W with comply with such provisions or this permit shall be TRAILER USE❑ GEOLOGY INSPECTION C1 No Spec. Knowl. El ~ deemed revoked. Panic Devices ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that I am licensed under provisions of Chapter SAFETY 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 full force and PARKING I'- effect. REQ'D � PROVIDED SPACES License Number Lic.Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). S 'PRESENT USE OF BUILDING `Ile, c. -' •-.. FINAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS ON LOT AND USE i s s s 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 SPACES PROVIDED Ell, as owner of the property, will do the work and the structures not intended or offered for sale (Section 7044, Business and Professions Code). L PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY }. I 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, TOTAL FEE and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date