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HomeMy Public PortalAbout5436 ENCINITA AVE_Building__ y1.r_ (o. z�Ia . 1�WORKERS' COMPENSATION DECLARATION' - Y"herela -affirm that have a certificate of consent to self D O �LI��Ip� FOR �L��q IJ Ml,/��. p �p}I��y��fLpy❑L� insure, or a certificate of Workers' Compensation Insurance, UPUC AMOL1 V. 0 OR BU L�D6 V V . PLSR V T • or p certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES - . . BUILDING AND SAFETY �S Policy,No. Company�''��� � F to - Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESSG ❑ rn3 ❑ Certified copy is filed with the county building'inspec- BURRING Sp ` &cw 2iA ve_ , tion department. _ I ADDRESS 4 DateApplicant CRL= .� C*4 CtF`:f�J clrr —S'�.A l�. C2i"- z16� �[ L 1Q 6LOCALITY EST _ CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT I Lal X1 I NO. OF BLDGS. NEAR = 11 ID.�NOW ON LOT CR 05 57. COMPENSATION INSURANCE F1NLML ASSESSOR (This section need not'be completed if the permit is for one TRACT at 18 BLOCK " LOT NO. MAP BOOK - - pgGE I PARCEL hundred dollars ($10D)or less.) .- TEL4L>If J USE ZONE MAP OWNER 1%4 r[.a QA'IZO NO. -4-J( NO. !/ •-/. " I certify that in the performance of the work for which this - ?.�-�f•G- VJLLlff'ial [ �� r SPECIAL— �I Y permit is issued, I shall not employ.any person in any manner ADDRESS .0 4- 1 - CONDITIONS ©�c,y.••.—• a so as to become subject to the Workers' Compensation Laws. - O . - CITY KorJ.(_CA - ZIP RO4-S U Date Applicant ARCHITECT OR TEL e p Dd NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER J L� r (AS✓oW'�`F-. NO.��a� p-221 DISTRICT .GROUP TYPE FIRE CESSED BY O _ CONST. ZONE U Exemption, you should become subject to the Workers' O •�` Compensation provisions of the Labor Code, you must forth- ADDRESS [ V Df tGJU^ ix �� U �' �3 7� ',w d with comply with such provisions or this ermit shall Fie Z d P Y P P •b TEL. STATISTICAL CLASSIFICATION / APT. CONDO. deemed revoked. CONTRACTOR NO. d-. ( LICENSED LA CONTRACTORS DECLARATION UC CLASS NO. DWELL. UNITS'1 I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. - SEWER MAP . (commencing with Section 7000)of Division 3 of the Business LIC _ -'-"- M and Professions Code,and my license is in.full force and effect. CITY CLASS BK PG VALIDATION - 1nf S1. fT a NO. OF NO. OF ii CHECK _ License Number Nil r'Irl .1 'tic. Class J1' SIZE' [ T STORIES �" fAMI LIES 1 ONE `{ 1'op o A g ..® VALUATION Contractor��f CkQN'HIZ'=-5rJDote 211 W DESCRIPTION OF WORK NEW $ p tl:(1 ACCT.: •--' ❑I am exempt under Sec. V2 I t-)rf of ARD ❑ D3307 431.09 _ALTER El - _ 1 ITEMS I �q� BP.C. for this reason REPAIR F-1 $EXI ' Date: USE OF .BBLDG. DEMOL'❑ .TOTAL 431.09— Signature APPLICA — 1 TEL g OWNER-BUILDER DECLARATION - (PRINT)NT NO. 8� _;1{ "FINAL CHECK - 431.09 ' DATE 1 hereby affirm that I am exempt from the Contractor's License .p C � FOCI ' Law for the following reason (Section 7031.5, Business and ADDRESSli&-S ci. 6AhPTeL FINAL- Professions Code): - PRESENT .. __By, _ . ,.-.._...... BUILDING I��T�OI�I� I'T�T e7� Op ❑ I, as owner of the property, or my employees with - ADDRESS "� r - yyUU=0001 E/31/Pi9 wages as their sole,compensation,will do the work and -- - - - — D j �j, . the structure is not intended or off eredfor sale(Section LOCALITY ;' j�' 1)f L,� .4n MOVING .TEL. 5a3- 1'. ..A1111. .c 7044, Business and Professions Code ) � - :.. � ; ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. ,1.. with licensed contractors to construct the project (Sec- - ADDRESS tion 7044, Business and Professions Code.) , AQCT..V. ... . - -. .-.-. REQUIRED TOTAL SETBACK FROM. EXIST. .._ 7 9a v 1•'IC '-i\1 �7 .� CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 1 hereby affirm that there is a construction lending agency for FRONT �t 1 ' t 1 the performance of the work for which this permit is issued P.I. - - ' .. 1 ITEMS (Sec. 3097, Civ: C.). SIDE .. P.L.. - _ .. F ^ .{ . ,1J_ ..TO1y�AL 735.00 Lender's Nome $ �Jf LDMA Ref. N_ ' f U ? '.• `rTLM �.00. P.C. Fee$ Permit Fee ✓ " r ' Lender's Address ' 1 _ CH � .0 I certify that I have read'this application and state that the 31'✓J Issuance Fee tDNA P/C N • 1 D - - 8 above information is correct. I agree to comply with all County Investigation fee '� "-- �•Ir��r•���B•LrI ordinances and State laws relating.to building construction, Total Fee -(.,/ LDMA Perm. N WLJIJ�AJU1 8(31(89 a and hereby authorize representatives of this County to enter iJUU7V��JUU O O] upon he aboy�-menti I ed property for inspection purposes. - - - - C.J4.]O 1 �11�4Q a C`x) _ SEE REVERSE FOR EXPLANATORY LANGUAGE _ Sign Lure of pplicant or Agent Date _ WORKERS' COMPENSATION DECLARATION t.,� p r� p I�F� /� f� f hereby affirm that I haver certificate of consent to a ce, - /py PPn C /Ep 7MN FOR �n n�n ®� e�n� Pl}I`y fryg P `TI'JII insure, or a certificate of Workers' Compensation Insurance, !!V L+L !/11 u V 11 1 B L�/ (Li u 'U' LS IIRUt7l1 or a certified copy thereof (Sec. 3800,-Lab. C.) "/ COUNTY OF LOS ANGELES BCl LDING AND SAFETY Policy No. Company M Certified copy is hereby furnished. - R APPLICANT TO FILL IN - BUI lNG � ADD SS Certified copy is filed•with the county building-inspec- BUILDING /� -- lion department. ADDRESS A_ Date - Applicant ,. CITY ZIP. IIALOCALITY Al CERTIFICATE OF EXEMPTION FROM WORKERS' y _ NO. OF BLDG NEAREST COMPENSATION INSURANCE - SIZE OF LO X� ON LO CRO ST. (This section need not be completed if the permit is for oneA SSOR hundred dollars ($100)or less.) TRACT I BLOCK LOT'NO. P BOOK PAGE PARCEL __ 'T SE NE MAP I certify that in the performance of the work for which this OWNER SNO PE permit is issued, l°shall not employ any person in any manner ADDRESS `L I � SPECIAL - so as to become subject to the Workers'Compensation Laws. CONDITIONS Q /ts 0clrr fl(60,1 ziP 0 Date Applicant zU ARCHITECT O T s NOTICE,TO APPLICANT: If, after making this Certificate of ENGINEER Vomit Nq;p LU ZZ - �DISTRICT'/ GR UP ttPE ////// FIRE PRO SSED BV Q Exemption, you should become subject to the Workers' J Q O CONS/ ZONE I-- -Compensation -Compensation provisions of.the Labor Code, you must forth- ADDRESS -�� _ Off\ s rj - W with comply with such provisions or this permit shall ba L. STATISTICAL CLASSIFICATION APT. C NDO. Tn deemed revoked. CONTRACTOR �� O. w LICENSED CONTRACTORS DECLARATION \. a ClAss NO. DWELL. UNITS—LL Z I hereby off irm that I am licensed under provisions of Chapter 9 ADDRESS 1 NO. 4 SEWER.MAP (commencing with Section 7000)of Division 3 of the Business and \ UC. _ Professions Code,'and my license is in full force and effect. CITY l I CLASS BK/LPG/ VALIDATION SO:FT. NO. OF O. OF CHECK , License Number Lic.Cions SIZE TORIES AMO oNE _ - 9 3 0.5 A --}} V1A, TION Contractor Date DESCRIPTION OF NEW D #Fele • e '2 3 I am exempt under Sec. C�o1. 0 ADD O s� -� / D - _( - 40698 V ALTER ❑ e a 4.0 6.9 8 U B.O.C. for this reason REPAIR. ❑ f/ Dote: - USE OF DEMOL EXISTING BLDG. Signature - APPPCRA I - �S NQ. FINAL OQ,�O�L;- 88 OWNER-BUILDER DECLARATION u.J�,f^^ ' C /DATE - hereby affirm that am exempt from,the Contractor's License 1�"LW Fri FINAL Law for the following reason (Section 7031.5, Business and ADD SS' Professions Code): PR ENDR T \ ''j BY ❑ BU DING 1, as owner of the property, or my employees with A ESS wages as their sole compensation,will do the work and \ / the structure is not intended or offered for sale(Section LACAUTY D _ 7044,'Business and Professions Code). MOVING TEL 1, as owner of the property, am exclusively contracting CONTRACTOR NO. , with licensed contractors to construct the project (Sec- ADDRESS Ilan 7044, Business and Professions Code). RE uI CK TOTAL PROP. IN - - 'CONSTRUCTION LENDING AGENCY � SET BACK YARD- MWY PROP. LINEWIDTH I hereby affirm that there is a construction lending agency for FRONT\ / the performance of the work for which this permit is issued ' •P.L. (Sec. 3097, Civ. C.). SIDE \ v.L. Lender's Name LDMA'Ref. # m P.C. Fee$ L Permit Fee D Lender's Address - I certify that I have read this application and state that the Issuance Fee LDMA P/C R S1. above information is correct. I agree to comply with all County Investigation Fee _ c ordinances and State laws relating to building construction, Total Fee LDMA Perm. p and hereby authorize representatives of this County to enter 9 upon the above-mentioned property for inspection purposes. m SEE REVERSE FOR EXPLANATORY LANGUAGE - Signature of Applicant or Agent Date -