HomeMy Public PortalAbout5340 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 75 (11-84)
CE 875 MISCELLANEOUS APPLICATION
CE 8
I h .reb affirm that I have a certificate of consent to self
insu e,;n`a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy theFeof(Sec. 3800,Lab.-C.).
Policy�o: Company FOR APPLICANT TO FILL IN BUILDING
.1 ADDRESS �"3�O
aCertified copy is hereby furnished. Bu sass ' �� LOCALITY
0 Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS ST.
Date Applicant NEAREST DISTRICT NO. G/FFFFR�/�UP TYPE ,y/,Y CESSED BY
CROSS ST. / P` CONST. '//
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o fj/
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NMAOP (CCRGLE)HIHWAY 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. -/
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 k OWNER
EZE
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUPADDRESS
Date Applicant I„
rEL. OCCUPANT LOAD
- NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. Z
-Exemption, you should become subject to the Workers' nn APPLICATION FOR EXIT HARDWARE: _
• Compensation provisions of the Labor Code, you must forth
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 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�C.�� /r ice'' REQ'D D PROVIDED
SPACES
License Number Lia Class — x;u7
/3Sd� X7716 ,�(o - LIMITED TIME USE
Contractor Date 1 ` DATE DATE
El _ J
I am exempt from the licensing requirements as I am a CCC/// /L-�'�'� FROM: TO:
licensed architect or a registered professional engineerSIZE OF OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. #FrORIES SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date 4i
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE .. w
I hereby affirm that I am exempt from the Contractor's
Licen Law for the following reason (Section 7031.5, Busi-
ness nd Professions Code): NO. PARKING :•.r.,a-.
I, as owner of the property, will do the work and the SPACES PROVIDED 1 I ;;;s.;
structure is not intended or offered for sale (Section s_)T AL 2314- 45
7044,Business and Professions Code).
PROPOSED OF BUILDING '�,:fi`i:.•': 'i'i'i{°+r'I
CONSTRUCTION LENDING AGENCY _
. i^ •t.( yl.. c j^II t
I hereby affirm that there is a construction lending agencyfor the the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name -_ p "• -_
PROPOSED MAX. OCC. Fi_'f _^7„1 •_S:i-°: .
Lender's Address
PERMIT FEE '''•`I�'' '9 �"J' -
I certify that 1 have read this application and state that the ,
above information is correct.1 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 61
upon the above-mentioned property r inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigyr ure o Permittee Date