HomeMy Public PortalAbout5729 ENCINITA AVE_Miscellaneous__ WORKF„'RS`COMPENSATION DECLARATION 76M444
- CE 875(11-B4) MISCELLANEOUS APPLICATION {�
I hereby 'affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION LJ
insure, or a certificate-6f Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.). _
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS s,7 �'l7i 4141;IA .0* 1AJ ,u
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Certified copy is hereby furnished. euILOE95 IING Al g/C_f411, bl/�. (�'(I LOCALITY
ADOR
Certified copy is filed with the county building inspection LOCALIT i i NEAREST L,�s 741%">
department.
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5T.
Date Applicant NEAREST / �J /)i/' DISTRICT NO. OUP TYPE PRO 'BY
CROSS ST. �` �� CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEG L
COMPENSATION INSURANCE DEs cRlPnory LOT NO. (O BLOCK HIGHWAY
HaP C,qC LwSTATE MAJOR SECOND LOCAL
y )�. 1 NO. OF BLD15.
(This section need not be completed if the work Involved TRACT S NV.V �/11. NOW ON LOT USE ZONESPECIAL CONDITIONS
by the permit is for one hundred dollars (§100) or less.) �/> USE of NN
SIZE OF LOT 7D,r/3 .Y f(j U' EXISTINGO�LF,D(4Wr, ;V/1lCZ' y
I certify that in the performance of the work for which this f fEl 03
permit is issued, I shall not employ any person in any manner OWNER (;/J41N &A.1 01(( A CW-Ul/41.6 A” n `o
so as to become subject to the Workers' Compensation Laws. 4 IMAIL / ..`, / ,1 OCCUPANCY GROUP G/_3
ADOR ESS Iy/ /P `�YCLN Z,�11
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY ,• -I/'(F'GL't ryoL �Q�6J. .r- fr.��U 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 ❑ 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
ness and Professions Code, and my license is in fUH'force and
effect. WJJ PARKIN gE0'D E= PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date ..TE DATM
El1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF ./ L / No. of / INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING w ELDe. 7 ^ f`� = 3. sr BRIG Sle TUBE
iness and Professions Code).
• A
PRESENT USE OF BUILDING FINAL APPROVAL
el LP
Lic.or Reg.No. � Date _hob
HOME OWNER-BUILDER DECLARATION NO.OF ii 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-
nes and Professions Code): NO.PARKINGy �,
SPACES PROV
IDEO
1, as owner of the property, will do the work and the i I=
structure is not intended or offered for sale (Section - v
7044,Business and Professions Code). i).l1 n�. 1 =4 f,5
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING rL�-h
C _
CHECK
�. rrl�.l-;
1 hereby affirm that there is a construction lending agency 1
for the performance of the work for which this permit is
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. 1 agree to comply with all County ISSUANCE FEE L 1�
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon the aomened property fo / [Ion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date