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Home My Public Portal About5812 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION a CE 875111.84) MISCELLANEOUS APPLICATION' CE 6] G 1 hereby, affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION IllJll insur�� or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. ADDouILDR EN55IG 12 Encinita Ave LOCALITY (1 Certified copy is filed with the county building inspection LOCALITY Temple City NEAREST department. IV CROSS ST. Date Applicant NEAREST N/Las Tunas-E Rosemead Blv OISTR ICT NO. GROUP CONST PROCESSED EY CROSS 9T. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCKMAP .="WA STATE MAJOR SECOND LOCAL NO. OF 84DOS. (CIRCLE) (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 (SI00) or less.) use of I certify that in the performance of the work for which this sae of Lor Exsnee BLDG. >" n 0 permit is issued, I shall not employ any person in any manner owNER Red Carpet—Bailey R s- so as to become subject to the Workers' Compensation Laws. •'� OCCUP.ANCY�GROUP�y wnowess 5912 Eneinita Ave . t � :, `s�,C. �+ \��j'A Date Applicant g Temple City TEL'(818) 285-9791 ' OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of urY r No. � Exemption, you should become subject to [he Workers' APPLICATION FO EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with Comply with such provisions or this permit,shall be TRAILER USE ❑ Geo GY 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 PER ❑ (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 full force and - effect. PARKING SPACES REO'D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATe I am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer zE OF No. oP INSPECTOR'SG acting in my professional capacity (Section 7051,, Bus- ..STING BLDG. sr DRIES sITURF iness and Professions Code). FINAL APPROVAL ✓/� / Lic.or Reg.No. Date PRESENT USE OF BUILDINReal Estate l HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's ;9 93 S 9 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING - #•• • • • 88 ElI, as owner of the property, f the work and the 5ACES PROVIDEO o structure is not intended or offered for sale (Section • e a • e • • z 7044,Business and Professions Code). PRorosep use of BUILD INc Rea Estate 04. 1 4 -88 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. C�-0 Lender's Name 1 PROPOSED MAX. OCC. Lender's Address •'1 vv 1 certify that I have read this application and state that the PERMIT FEE , above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE up n the about-mentioned property fopr inspection purposes. oC(�tirp "D41 r1�4 -3� SEE REVERSE FOR EXPLANATORY LANGUAGE ig f Date .1 WORKERS'COMPENSATION DECLARATION 76M444 CE 675 (2-80) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insureyor a certificate of Workers'Compensation Insurance,or . a ceftified coy thereof(Sec. 3800, Lab,C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished. SyILD]NG N NI AVE �. LOCALITY oOREss Certified copy is filed with the county building inspectionJ NEAREST Loe ulTv department. CROSS ST. U3[e Applicant DISTRICT NO. VP TYPE PRoc SSE BY CROSS ST. CONST: / CERTIFICATEOF EXEMPTION FROM WORKERS' LEGAL ✓(� J V COMPENSATION INSURANCE vast RIRTI DN LOT NO. BL.CK e`. Ld O�j mn W. Y M // STATE MAJOR EECOND LOCAL �neLel (This section need not be completed if the work involved (� Noof BLDGs. . " a0 p TRACT J / NOW ON LOT USE ZONE SPE IAL CONDITIONS by the permit is for one hundred dollars (5100) or less.) �Z U r Mfr USE OF /1 SIZE OF LOT K S k (/ E%ISTING BLDG. l� L/• 1 certify that in the performance of the work for which this a permit is issued. I shall not employ any person in any manner OWNER Iwo HIL-1- f so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP — Z- U GRE55 4.) Q• LU Date Applicant fA ^..('�[�,� TEL -;8'0 - 637-q OCCUPANT LOAD Z NOTICE TO APPLICANT: If, after making this Certificate of clrY -LO /•J/N rvo. 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. ❑ Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION I hereby affirm that 1 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 andII cant's Name — MoSES ILL PARKING• effect. SPACES REO'O E PROVIDED License Number Lie.Class H—Qme_Address — •�� — Mil-TOA) y� LIMITED TIME USE Contractor Date Grr�r.'rare/! (,.A�' 6 o.re DATE I am exempt from the licensing requirements as I am a hone — licensed architect or a registered professional engineer SIZE of .. No. OF INSPECTOR'S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG. p STORIES SIGNpTDRE iness and Professions Code). ESENT Use OF BUILDING /N5*14 k4N e:C FINAL APPROVAL Lie.or Reg.No. - Date / IId / f�.•p,y,•J Lf HOMEOWNER-BUILDER DECLARATION OOF USG BUILDINGS ON NoLOT AND D USE I hereby affirm that- 1 am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- - 1 7 3 8 A ness and Professions Code): NO. PARKING 13 SPACES PROVIDED _ 1, as owner of the property. will do the work and the � e a L • 4_Q structure is not intended or offered for sale (Section 7044, Business and Professions Code). E/�L C A• E 0 0 0 0 0 0 0 • ROPOSEO USE OF BUILDING , CONSTRUCTION LENDING AGENCY ' ,O a 1 5-80 1 hereby affirm that there is a construction lending agency 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 1 certify that I have read this application and state that the above irformation is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building Construction, TOTAL FEE aQdPhereby authorize representatives of this County to enter upon the ubpve-mentioned property for inspection purposes. SEE REVERSE h R EXPLANATORY LANGUAGE SiglLture of Permittee Date WORKERS'COMPENSATIONDECLARATION 76M444 87544 (2-80) MISCELLANEOUS APPLICATION {� lJ 1hereby affirm that I have a certificate of consent to self ' COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insu e, or a.certificate of Workers'Compensation Insurance,or a certified copy thereof(Sea 3800, Lab.CJ _ eunDI Policy No. Company FOR APPLICANT TO FILL IN wo DRENGss .S ' ❑ Certified copy is Hereby furnished. DUILDING Z. LOCALITY , DDREB{ (_. F-1Certifiedcopy is filed with the county building inspection 655� NEAREsr ;^ / department. LOCALITYeGoss ST. FC{� Date Applicant NEAREST ' DISTRICT N OVP TYPE PROC SSED BY CROSS ST. — CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL DESCRIPTION LOT NO. BLOCK } COMPENSATION INSURANCE NOP CIRC STATE MAJOR SECOND LOCAL No. OF BLDGS. (`� LEI 0 (This section need not be completed if the Work involved TRACT s NOW ON LOT USE LONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) USE OF E z Q SIZE OF LOT EXISTING SLOG. I certify that in the performance of the work for which this 0 D� Irv, O permit is issued, I shall not employ any person in any manner owNER �I U so as to become subject to the Workers' Compensation Laws MAIL a OCCUPANCY GROUP y� LU ADDREBS /�/ U' Date Applicant L p N NOTICE TO APPLICANT: If, after making this Certificate of ITV pe.,. n Is 7^5 76 -7 OCCUPANT LOAD z Exemption, you should become subject to the Workers' GPtf 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 ChapterSAFETY 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 Pw RxING. REdD PROVIDED effect. . SPACES License Number Lie.Class LIMITED TIME USE Contractor. Date DA.E D.Te ❑ ,I am exempt from the licensing requirements as I.am a licensed architect or a registered professional engineer SIZE OF 1(3-700 No. of / INSPECTORSIGNATURE acting In my professional capacity (`Section 7051• Bus- EXISTING BLDG. STORIES In255 and PrOfeaaIODS Code). PRESENT USE OF BUILDING �- FINAL APPROVAL Lic,or Reg.No. Date ✓ HOME OWNER-BUILDER DECLARATION NO. of EXISTING Bm LDlrvcs - ON LOT AND USE 1 hereby affirm that- I am exempt from the Contractor's License Law for the following reason (Section 7031.5. Busi- y ness and Professions Code): No' PAR' 'rI • C 3.72 9 A SPACES PROVIDED G may-. 1 ❑ 1, as owner of the property, will do the work and the . structure is not intended or offered for sale (Section e e s • Q O 7044. Business and Professions Code). Z.OPOSE. USE OF 6OILDING CONSTRUCTION LENDING AGENCY ' 1 hereby affirm that there is.a construction lending agency ,011. 1 3' ,-81 for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. Oce., Lender's Address PERMIT FEE Inv I certify that I have read this application and state that the ' above information is correct. I agree to comply I all County ISSUANCE FEE ordinune to lacing to build' g construction, TorAL FEE and eby auth rie re �tat- /Cp;`P p n the abov ment spec[ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE C/ ig e( ermittee Date -