HomeMy Public PortalAbout5702 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATIONsmaaa
ff, (JW CE 875 (11-84) M ISCELLANEOUS APPLICATION {�
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I herebyF•affirm ;heat I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.Q. _
Policy No. Company FOR APPLICANT TO FILL IN RU ILoING
ADDRESS
ADD
Certified copy is hereby furnished. RU.RESS S. LOCALITY
DCertified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS sr.
Date Applicant NEARESTOak / DISTRICT R G 'u� CGNST. PROCES D RY
CROSS ST. St/�' /JJ�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEcwL n
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK C/ (CIRCLE) STATE MAJOR SECON LOCAL
NO. OF BLDGS. nD
(This section need not be completed If the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG.
I certify that in,the performance of the work for which this , o
permit is issued, I shall not employ any person in any manner OWNER /{J
so as to become subject to the Workers' Compensation Laws. '
Mw IL OCCUPANCY GROUP: \ ` ED
ADDRESS
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of m'rY .gym / ,G i no� ' . 00CUPANT LOAD z
Exemption, you should become' subject to die Workers' APPL CATION 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 ❑ 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).
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS EJ
ness and Professions Code, and my license is in full force and PER�A/I
effect. /f Fi /d - //I I I� n PARKING REO�D � PROVIDED
7 `-' �W1 — 1*P_i sPwe:Es
License Number Lia Class LIMITED TIME USE
Contractor Date 'NO NIG [ I]� DATE DATE
I am exempt from the licensing requirements as I am a Ll/ ae
licensed architect or a registered professional engineer SIZE OF No. of 15 GNATURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES
iness and Professions Code).
PRESENT USE OF BuILDINc 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
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING '
El1, as owner of the property, will do the work and the SPACES PROVIDED +
structure is not intended or offered for sale (Section # . e -.630
7044,Business and Professions Code). 11,• - 8 (16,0
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING - e • e 815 0 5
I hereby affirm that there is a construction lending agency - -
for the performance of the work for which this permit is - :1 0 05 �8 7.
issued(Sec. 3097,Civ.C.).
Lender's Name ,
PROPOSED MAX. OCC.
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, r
and hereby authorize representatives of this County to enter TOTAL FEE 1
upon the above-mentioned property for inspection purposes.
^ SEE REVERSE FOR EXP ANA CRY LANGUAGE
( N/l � c7Ln e� cl - 3b-B7
ignature of Permittee Dale