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Home My Public Portal About5434 ENCINITA AVE_Building__ WORKERS' COMPENSATION DECLARATION - ti: /� 1�1� /,i /� r�� rte- 1�p p p 1� p�y� 1�p�r �T �7 G� hereby affirm that haver certificate of consent to self /p� PPLf ,f /(\%1710 IV�II .�O 1�(II II D�1161L([ e, I;.11}1=(,ry O 11 insure or a certificateof Workers' Compensation Insurance, - lf'1111 , ll Vlr�l Il V YY 00. LJ `Lh LLSS U V`! U IS BOOCY I! B or o certified coI py thereof (Sec 3800, Lob-C.) COUNTY OF-LOS ANGELES 'BUILDING AND SAFETY Policy No. Company}y�iQtu3+S I SuSiiIL.X.c fA, ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN - Boos 55 ' 6 33 ❑ Certified<o is filed with the count building ins so- BUILDING - -- - tion department: Y g , p ADDRESS - 8 cYJGwil /�✓� - - - DareA IL<am CFIG.2{'u,-CaTn�.CtiKt�� CITY' &CA J C.?"C � ZIP -'7,�;tJ - LOCAUTY . Pp "� ^ .f 1 . NO. OF BLDGS. 1 NEAREST= CERTIFICATE OF EXEMPTION'FROM WORKERS; SIZE OF LOT'GJ>'L:(S� -17 lnc NOW ON LOT CROSS ST COMPENSATION INSURANCE - PILrIGK -- - - ASSESSOR' r .. ' (This section need not be completed if the permit is for one - TRACT Q'ya i' BLOCK IS LOT NO. MAP BOOK,.- PAGE PARCEL hundred.dollars ($100) or less ) - TEL. t?t _ OWNER .F1ioV_A' of NO. 1 -SVA USE SONE NO. I certify that in the performance of the work for which this - l///i`/7 - - - - -permit is issued, I shall not em to an person,in an 'manner ADDRESS-,JC" A 44 - PECIAL d - P P Y Y P Y CONDITIONS t O so as to become subject.to the Workers'Compensation Laws. t....- , , _ .,, - - U - CITY j/ . -'A (L ZIP cZE^s4 .Date - Applicant IARCHITECT OR TEL• ``'''' DISTRICT EST 'FIRE CESSED'BY O NOTICE TO APPLICANT: If, after making,this Certificate of ENGINEER UE S a1W NO.(A? '311 - - - CONST. ZONE Exemption,.,you should„become .subject to the Workers' ��rSC'�L�'R-tlTa7 GRduJ� r1Y, # - �O Compensation,provisions.of the Labor Code; you musts Orth- . ADDRESS_-- w �+ Q_ with comply with such provisions or this permit shall be. TEL STATISTICAL CLASSIFICATION , ' AP,T. CONDO. - Z s'deemed revoked. 'CONTRACTOR NO. q ( LICENSED,CONTRACTORS DECLARATION r, - UC. CLASS NO. DWELL,UNITS / 'tl I hereby affirm that I am licensed under provisions of.Chopter 9 _ ADDRESS NO, - SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code;ondmy license is in full force and effect. - CITY CLASS BK �G VALIDATION y :r SQ.-FT , 11 NO. OF_ NO. OF CHECK - - License Number 531 nth 1 Lic. Class ' ','T SIZE- a STORIES 1 FAMILIES ONE 21 _ '}r VALUATION I Confraciorl �q •.)7 [.]{ (Tm� Date a�I q DESCRIPTION OF WORK NEW a. ACCT T' , rh^r 1 P( , .. _. . ADD ❑ $ - -D' ❑1 am exempt under Sec. n'E frdEF-)n�. Ctw f3.�l 3307. . . . _ 431.0? B.BP.C. for this reason ,.1 . .ALTER .❑ - $ - , 1 ITEMS - 'REPAIR 0 ., _ _ _ •tAT 1LLLJ y. ' Date: _ USE OF EXISTING BLDG. y 'DEMOL ❑ -TOTAL '431.09 APPLICANT TEL Signature - ' - PRINT - -31( FINAL CHECK. Q1.09 OWNER-BUILDER DECLARATION L 1 � �` NO. l!9,,�)`` / DATE L.�� - I hereby affirm that I am exempt from the Contractor's License -' qD(PRINT) U t Q� ri aft. -k 5 1a�166GPc l FINAL' CHAH�E .QU Law for the following reason (Section 7031.5, Business and Professions-Code): - ' .. PRESENT _ - - —Ey .- ......__.-,. a : - ❑ I, os owner of them or ro ert , o BUILDING ,. P P Y Y employees P Yees with ADDRESS �': VUVU-0001'. E/JI/G] wages as their sole compensation,will do the work and the structure isnot intended or offered for sole(Section LOCALITY / .5433 1 AM11-+1.- ❑ 7044, Business and,Professions Codev) - - MOVING- - - - - TEL - - Y 1 I, as owner of the property, am exclusively contracting CONTRACTOR NO. nM! + -with licensed contractors to construct the project (Sec- ADDRESS 1 t IPII A' tion 7044, Business and Professions Code.) �c\ ` r e �CT.4 ' REQUIRED - TOTAh'SETBACKFROM EXIST.. T 'a ,t�tt��,P� ,'�307 .7J'S o0 CONSTRUCTION LENDING AGENCY - SET BACK YARD HWY PROP. LINE WIDTH. I hereby affirm that there is a construction lending agency for ' FRONT _ x�\ v\ {L�c� 5 \� 1 ITEMS the performance of.the work for which this permit is-issued 'P.L. - - (Sec. 3097, Civ. C.). SIDE . 'I P 1 `TOO AL 735 m 00 _ PAI. �y Lender's Name. - CHECK ? LDMA Ref p m •.` - P.C. Fee$ Perm it'Fee � V D ..C(1N717C � •QQ , Lender's Address � - I certify that I have read this application and state that the l U Issuance Fee LDMA PK p above information is correct. I agree to comply with all County Investigotio Fee ordinances and State laws relating to building construction, Total Fee 3S U D LDMA Perm. p D000-0001 Qv7,1/391 and hereby authorize representatives of this County to enter _ y U N ^ upon the obo e-mentipDed property for inspacti purposes. - 54Q'� 1 A1111$(f.� CAI G)-- L.I�) '/ ' SEE REVERSE FOR EXPLANATORY LANGUAGE Sig tore of pplicant or Agent WORKERS' COMPENSATION DECLARATION re y APPLOC�AIMN FOR CD3MOdMMG P[EG36�1�T u Ihereb affirm that I have a certificate of consent to self D O O O O D insure, or o certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab'. C. " ' COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. - Company BUILDING F-1Certifiedcopy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 3 ❑ Certified copy is filed with the county building inspec- BUILDING ` .� lion department. ADDRESS Date Applicant CITY lc ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' I NO. OF BLDGS. . NEAREST COMPENSATION INSURANCE SIZE OF LOT c L), NOW ON LOT CROSS ST. (This section need not he completed if the permit'is for one > ASSESSOR hundred dollars ($100)or less.) TRACT 3 BLOCK LOT NO. MAP BOOK I PAGE PARCEL I certify that in the performance of the work for which this OWNER �- US NE - MAP permit is issued, I shall not employ any person in any manner �F.� — ECI I so as to become subject to the Workers'Compensation Laws. ADDRESS ILS 4 C NDITIONS O CITY 4!WTA M00CA ZIP .1764121' U Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of ARCH ECT �1 TEL DIST DIST G O FIRE PRO ESSED BY O Exemption, you should become subject to the Workers' ENGINEER• s/ N WO ,� ONST. ZONE U Compensation provisions of the Labor Code, you must forth. ADDRESS a Nps bs2 ` v 3 W with comply with.such provisions or this permit shall be0-1 / L. STAT T L CLASSIFICATION APT. 0 W. - Tn deemed revoked. CONTRACTOR NO. z LICENSED CONTRACTORS DECLARATION - uTe, CLA NO. DWELL UNITS ' 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NOT S W MAP ' (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS / gK LPG VAC1� 16'A SO. FT. D NO.OF NO.OF CNE K License Number LIC.Class SIZE STORIES � FAMILIES ONE, e e e 23 � I� Gyp VALUATION DEBCRIPTI NOF WORK NEW ' t� I • '4 0 6 9 8 Contractor Date s ❑ 1 am exempt under Sec. ry,> DD C] D ° ° 4 O 6 9 8 A TER B.BP.C. for this reason REP IR ❑ s 0 4..0 4=.88 ' DUBE OF Date: / DEMOL ❑ EXISTING BLDG. Signature ` APPLICANT 1+ TEL. FINAL OWNER-BUILDER DECLARATION PRINT J O. DATE _ I hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): - /❑ By BUILDING 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and , D the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING - TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACT NO, with licensed contractors to construct the project (Sec- - ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY SETT BACK YA HWY IOTA PROP.ACK FROM LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.I. - - (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name DMA Rai. q m Lender's Address P.C. fee$ Permit Fee D - I certify that I have read this application and state that theIssuance Fee LDMA P/C p above information is correct. I agree to comply with all County Investigation Fee q ordinances and State laws relating to building construction, Total Fee IDMA Pa, e and hereby authorize representatives of this County to enter $ upon the above-mentioned property for inspection purposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dote