HomeMy Public PortalAbout5472 ENCINITA AVE_Building__ *ERS'COMPENSATION DECLARATION
aft"n-Choi i have r certificate consent to self � A �� ® BUILDING
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brtd certificate of Workers' Compensation Insurance,
c." certified copy thereof (Sec. 3800, Lab. C
COUNTY OF`L`08,ANGELES+ BUILDING AND SAFETY
Policy No. Company —
F7 Certified copy is-hereby-furnished: FOR APPLICANT TO FILL IN BUILDING
ADDRESS C✓JJaj�,�./j
�ertified copy is filed with the-county building inspec- BUILDING �'
L--J tion department: --l_ ADDRESS �.7Z
Dote APPlicantr!/ s i` jt CITY j T ZIP _ 94'- E LOCALITY t,
ERTI KATE OF EXEMPTION FRO Opy ER • L� NO. OF BLDGS. NEAREST
COMPENSATION INSUR CE y SIZE OF LOT �CC NOW ON LOTS CROSS ST.
(This section need not be completed if the permit is for one TRACT / ! 7/J" BLOCK LOT NO. ASSESSOR%
hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL
J TEL. USE NE MAP �!
I certify that tr the performance of the work for which this OWNER,- /L�s✓z �, �,1>�✓�_/ NO� L � NO. 'C✓
permit is issued, I shall not employ any person in any manner ADDRESS!/ter: %✓ ls��t�'� SPECIALi
so cis to become subject to the Workers'Compensation Laws. CONDITIONS O,
CITY ZIP.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR – TEL PR ES5ED BY DISTRICT .GR UP TYPE FIRE O
Exemption, .you should become subject to the Workers' ENGINEER NO., CONST ZOt� V
Compensation provisions of the Labor Cade, you must forth- ADDRESS L ( V W.
with comply.with,such provisions or .this permit shall be 0..
deemed revoked. TEL. STATISTICAL CLASSIFI ATION APT. LONDO. - Cn
Z
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO-
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER P
Professions Code, and my license is in full force and effect. CITY CLASS, BK. PG. � VALIDATION
SQ. FT.- NO. OF / NO. OF CHECK
License Number Lic.Class SIZE 2. STORIES / FAMILIES ONE
�
VALUATION/Z
Contractor Date DESCRIPTION OF WORKI�`7"t` r%-�» 7 NEW
/i
❑I am exempt under Sec. ADD Cl– �r E] plop.
BAP.C, for this reason_ <% '?yam•"� REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT
T)C L is!s yV��j. t ,TEL ��v`rl� ' FINAL y R $ A
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS -- �? `� Fl / o 0 o e 2 3
Professions Code): PRES N . . 1fI e / Li rf 7
BUILDING
1, as owner of the property, or my employees with ADDRESS
l
wages as their sole,compensation,ensation,will do the work and
9 P LOCALITY ® ;i : �� o a 7 4 3,U n/
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). MOVING- TEL.
I, as owner of the property„ am exclusively contracting CONTRACTOR NO. e
with licensed contractors to construct the project(Sec- ADORES a
tion 7044, Business and Professions Code). 5
REQUIRED TAL SETBACK j +
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOFRpROP.'LINE WIDTH o o 8 5A j 5, j
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. -_ I 2_ n� p
(Sec. 3097, Civ. C.). SIDE
P.L.
=
Lender's Name •� f 1
o P:C. Fee.$ t 1c Permit Fee _ 2 LDMA Ref, #
Lender's Address
I certify that I have read this application and state that the Issuance Fee . /� kA P/G#
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, r
R and-hereby authorize representatives of this County to enter Total Fee LDMA Perm w# a
upon the above-mentioned property for inspection purposes.
a •cif SEE REVERSE FOR EXPLANATORY LANGUAGE
Siy ure of ppli nor` gent-7— Date' -- r