HomeMy Public PortalAbout5734 ENCINITA AVE_Building__ COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self insure, BUIL^INC ADOR SS
or a certificate of Workers'Compensation Insurance,or a certified `j A�.✓�A T� `� 73 A VT) A-y f`i
Copy thereof(Sec.3800,Lab.C.) CITY ZIP ter-//, t7�
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Policy No. Company SIZE OF LOT _ / NO.OF SIDES.NOW ON LOT
❑ Certified copy is hereby furnished. Q Z ��� NEAREST CROSS ST.
❑ Certified Copy Is filed with the county building Inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
ASSESSOR MAP BOOK PAGE PARCEL
Dale Applicant SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' oz
C TEL NO. YES �NO
COMPENSATION INSURANCE G ��� WITHIN 1"FT OF SCHOOL?
ADO ESS /
(This section need not be completed if the permit is for one hundred ��eiN��� � SAS-7/`/ DISTRICT GROUP TYPE CONST. FIRE 20NET
E BY
dollars($100)or less.) CITY ZIP I certify that in the performance of the work for which this permit L IIIT fO 50 3 3 . /T'
is Issued, I shall not employ any person In any manner So as to ARCHIT T OR ENGINEER TEL NO.
become subject to the WDrkerS Compensation Laws. /4/////& STATISTICAL CLASSIFICATION APT CO O
Date Applicant ADDRESS Q CLASS NO, DWELL UNITS
�O ���
NOTICE n, APPLICANT: If, after making this Certificate s' REQUIRED TOTAL SETBACK FROM DT
Exemption, you Should bebome Subject t0 the Workers' CONTRACTOR TEL.NO, SETBACK YARD HWY POOP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwithFRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.N0. P L .
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LICENSED CONTRACTORS DECLARATION clrY LIC.cuSIDE ss P L -_11-7 c i I o
4. cD
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP
(commencing BCbFJ.>AZE� NO.OF STORES NO.OF FAMILIES j'�'" p
Professions
with Section 7000)of Division 3 of the Business and 95 NEW ❑ BK PG 1 I i.
Professions Code,and my license is in full force and effect. A c t—
License Number Lit.Class DESCRIPTION OF WORK ADD VALu n0N !E t i rtL 4 15 ® '`0 W
d
Contractor Date ...5 D ALTER ❑ s.43,3 �� CHECK 41.1,+I_Z
a L/lr/�✓ aoM REPAIR ❑ CHANGE =fl!1
El am exempt under Sec. $ ... -
B.&P.C.forthis reason ING BLDG
USE OF EXISTDEMOL ❑ LDMA P/Cp ..ss
Date: . LIRM ❑ 01.300-0001 ?/ 6/90
Signature APP LICA T tPRINT) opTEL.NO. o LDMA Perm N = AM 10•._y
❑ I, as owner of the property, or my employees with wages as O
their sole compensation, will do the work and the structure is ADDRESS Q/r ` r
not intended or offered for sale (Section 7044, Business and G FINAL DATE Q
PF01e5510n5 Code.) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL O
J
❑ I, as owner Of the r0 ert , am exclusive) contractin with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN
P P y y g THEAMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project.(Section 7044, YES❑ No❑
Business and Professions Cade.)
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANTREQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST
FORGUIDELINES. I t
I hereby affirm that there is a construction lending agency for YES❑ No❑
the Performance of the work forwhich this permit is issued(Sec.
1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD
SORT"0V.I C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES
t 1 COUNTYCOOE,TITLE2,CHAPTER2a1SECTIONS 2.M.IWTHROUGH 2MAQ CONCERNING 1
BIT Mame HA RDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THESCAOMD.
Lender's Address onNen oBwwT _
o I certify that I have read this application and state that the above
f� information is Correct. I agree t0 comply with all County P.C.FEE '.J PERMIT FEE
a Ordinances and State laws relating to building construction,and hi F1 q
hereby authorize representatives of this County to enter upon ISSUANCE FEE VVI
the above-mentioned property for inspection purposes.
< INVESTIGATION FEE TOTALFEE
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SEE REVERSE FOR EXPLANATORY LANGUAGE