HomeMy Public PortalAbout5520 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (2-80) MISCELLANEOUS APPLICATION
heof affirm
t ate I have Workers'certificate
of consent Ito
if COUNTY OF LOS ANGELES 'BUILDING AND SAFETY DIVISION
In r r o
a certified copy thereof(Sec 3800,Lab C)
Policy No Company 4 FOR APPLICANT TO FILL IN BUILDING ' / , �Ji TA- AV&,
ADDRESS l..
Certified co is hereby furnished r LOCALITY
copy hbfhd BUILDING
ADDRESS
IDCertified copy is filed with the county building inspection NEAREST
department LOCALITY _ CROSS ST fl[
Date Applicant NE'pREST fy��� D13TRT�(QQ// G OU�j TYPE / JPRO713 BY
CROSS ST iilL�`.•JJ WW�J /Uj� Ij1 CONST
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL
t, DESCRIPTION LOT NO BLOCK }
COMPENSATION INSURANCE MAP (CIRCLE)
WAY
' rvo (CIRCLE) STATE MAJOR SECON LOCAL d
(This section need not be completed if the work involved No of BLDGs
p TRACT ' NOW ON LOT USE ONE SPECIAL CONDITIONS' O
by the permit is for one hundred dollars' ($100) or{less) r/ US of i
U
O
SIZE OF LOT 1f ; EXISTING BLDG `
I certify'that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner OWNER �l N&AJCp _1 `dA !—
so as to become subject to,the Workers' Compensation Laws OCCUPANCY GROUP 5 UJI
U
MAIL' ADDRESS �Sa'� &j(./Ni TA CL
Date Applicant - z
NOTICE TO APPLICANT If, after making this Certificate of CITY 'TJ91 L' �.IT� NOL -- o OCCUPANT LOAD
Exemption you should become subject to the Workers' APPLI ATION FOR EXIT HARDWARE
Compensation`provisions of the'Labor Code, you,must forth
with comply with such provisions or this permit shall be TRAILER USE 0 GEOLOGY INSPECTION❑ _ No'Spec Knowl ❑
deemed revoked ❑
L * occuvprvcY INSPECTION Panic Devices
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter' SAFETY PERMIT'q (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section'7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and PARKING:
D PRO
effect REQ'D VIDED O
SPACES
License Number Lic Class
LIMITED TIME USE
Contractor Date DATE DATE
' - 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 in my professional capacity (Section 7051, BUS- EXISTING BLDG STORIES GNATURE
,mess and Professions Code) PRESENT USE OF,BUILDIN'G FINAL APPROVAL
Lic or Reg No Date J
HOME OWNER BUILDER DECLARATION ON LOT ANNo of EXISTING BUILDINGS I
• D USE
I hereby affirm that I am exempt from the Contractor's r
License,Law for the following reason (Section 7031 5, Busi-
ness and Professions Code PARKING
) SPACES PROVIDED
1, as owner,of the property, will do the work and the ; q 4 7 a A
structure is not intended or offered-for sale (Section.
oRo ,
7044, Business and Professions Code)
, PROPOSED USE OF BUILDING ,o s 3�
` CONSTRUCTION LENDING AGENCY ( ZI s i 'o ° 8 Q 5
I hereby affirm that there is a construction lending agency o e o 8 a 5 Q=ar
for the performance of the work for which this permit Is c
Issued(Sec 3097,Civ'C )
Lender's Name0 610 9-8 6
PROPOSED MAX OCC 1
i
Lender's Address PERMIT FEE ~
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
ordinances and State laws relating to building construction, TOTAL FEE Wu
and hereby authorize representatives of this County to enter
UP
on the bove mentlo ed property for inspect on urposes SEE REVERSE FOR EXPLANATORY LANGUAGE
—S—ii—nature o rmittee Date "