HomeMy Public PortalAbout5405 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION
CE 875 (11-84) MISCELLANEC-�USAPPLICATION
CE 875
,[ hereby_affirm *at i have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certifl'cate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS -V�l
Certified copy is hereby furnished. BUILDING �y •O� N�G��,� �� ♦tJ LOCALITY
S
ADDRES ,�' C/L
❑ Certified copy is filed with the county building inspection LOCALITY NEAREST
department. /e,-J I CROSS ST.
Date Applicant NEAREST v DISTRICT NO��� �FOUP TYPE P SSED BY
CROSS ST. C// v` �D/ _3 CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SECOND LOCAL
�J/ y/- NO. OF BLDGS.
�
(This section need not be completed if the work involved TRACT O / " / ,I6 NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (5100) or less.) / usE of
SIZE OF LOT E7, �� './'T; EXISTING BLDG. �G'j d
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 OWNER /J�7/e5 /1/02��'i/J S14V 4� ''
so as to become subject to the Workers' Compensation Laws. MAIL �^ OCCUPANCY GROUP ® o
ADDRESS •S/3 ���((, C.7
Date Applicant /�. I„
L.
NOTICE TO APPLICANT: If, after making this Certificate of CITY1A a-, NO
�"C4/L�' . OCCUPANT LOAD N
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION 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
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 //�� 'J /�� '
effect. hddi ,0 �//-" �`' i/'�� PARKING
n SPACES REq'D D PROVIDED D
License Number Lic. Class 2 /`"O/1 G n �� S U/Z
LIMITED TIME USE
Contractor Date l DATE DATE
ElI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INS PE
CTO R'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF USE BUILD GS
ON OT AND
I hereby affirm that I am -exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- ` Y:(_l.;
ness and Professions Code): NO. PARKING - - -
SPACES PROVIDED
❑ I, as owner of the'property, will do the work and the _ _ s
structure is not intended or offered for sale (Section ! _
7044,Business and Professions Code). ..L_
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
I hereby affirm that there is a construction lending agency s(_} aj j
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC. I Ei'i)-S jl •! + i�.r'1
Lender's Address
PERMIT FEE �7 `
I certify that I have read this application and state that the S. =r.
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 1,3 7
upon he above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee 7 to
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