HomeMy Public PortalAbout5454 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (2-60) 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 �?ificate of Workers'Compensation Insurance,or
a certt�ed�py thereof(Sec. 3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN BUILDING.
ADDRESS
❑ Certified copy is hereby furnished. BUILDADDRESS ING — C r LOCALITY
Certified copy is filed with the county building inspection NEAREST
department. LOCALIT_ , CROSS ST.
Date Applicant NEAREST DISTRICTNO GRQVQ�P TYPE PRO E ED,BY
CROSS ST. 3 COV.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE
DESCRIPTION LOT NO. BLOCK MAP (CIRCLE)
LSTATE MAJOR SE OND LOCAL }
NO. (CIRCLE) 0
(This section need not be completed if the work involved NO. OF BLDGS. 0
p TRACT NOW ON LOT US ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.)
USE of
SIZE OF LOT EXISTING BLDG. '_ 0
I certify that in the performance of the work for which this 0
permit is issued, I shall not employ any person in any manner OWNER. w U
so as to become subject to the Workers' Compensation Laws. MAIL S �. �` yrs–'rZ�t��+�G�. �L�W� OCCUPANCY GROUP /� d
ADDRESS C. Cl)
Date Applicant '
NOTICE TO APPLICANT: If, after-making this Certificate of CJ Tr T OCCUPANT LOAD
Exemption, you should become subject to the Workers' (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 0 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)
NO. of Exlrs
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING.
effect. SPACES REq'D E= PROVIDED D
License Number Lic.Class
_ LIMITED TIME USE
Contractor Date � > y DATE DATE
a _ 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 m my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's I / '
License Law for the following reason (Section 7031.5, Busi-
NO. PARKING ^_
ness and Professions Code
SPACES PROVIDED
El [, as owner of the'property, will do the work and the
.structure is not intended or offered for sale (Section �s
7044, Business and Professions Code).
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY 'I (� z 4'7 1.,q p
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is # D D D o 3 0
issued (Sec. 3097,Civ.C.).
Lender's Name _ PROPOSED MAX. OCC. I D - 80,50
Lender's Address PERMIT FEE l U O D O 8 0.5 0i�
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 l9 iso 05,2 8=8 6
ordinances and State laws relating to building construction, TOTAL FEE
i andhe by authorize represents Ives of this County to enter
upo t ab
Signature
p� inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee �G Date