HomeMy Public PortalAbout5824 ENCINITA AVE_Miscellaneous__ •WORKERS'COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION
CE 8]a 11184)
I hereby affirm that I have a certificate of consent to seB COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.). f
Policy No. CompanyAPP ANT TO FILL IN nnnwess J nL\
Certified copy is hereby furnished. BUILo1N EN-)C1.-hTI �•
ADDREss LOC%LITY
Certified Copy is filed with the county building inspection
department. —1L M LE GT TY. NEAREST
LOCALITYCROSS ST.
Date Applicant NEAREST Q[ HJT y DIS RICT No. OUP TYPE P CE$SE BY
CROSS ST. - j, f� (lNJ O^1 Vv A ' / CO NST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 6
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOC. MAP ....N. STATE MAJOR SECOND LOCAL
no. OF BLDGs. (cincl.l
(This section need not be completed if the work involved TRACT rvow ON LOT � ' VSE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) u0E of D
SIZE OF LOT EXISTING BLDG. JN —� Y
I 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 R I{,J OEC:) P. U
so as to become subject to the Workers' Compensation Laws. LOCCUPANCY GROUPO_
MAIL
R ESS l '' �
Date ADD
Applicant cD
TELOCCUPANT LOAD d
NOTICE TO APPLICANT: If, after making this Certificate of CITY ANo .. 7
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with Comply With such provisions oI 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
9 (Commencing with Section 7000) of Division 3 of the BusF SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO, Or EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING p800 � PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE AT.
ElI 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. sT OR IES sINATURE
iness and Professions Code). FINAL APPROVAL +]L I
Lic.or Reg. No. Date PRESENT USE or BUILDING s
HOME OWNER-BUILDER DECLARATION No. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that 1 am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): No. PARKING
ElI, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
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.C.).
Lender's Name
Lender's Address
PROPOSED MAX. OCC.
QPERMIT FEE lo
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 O
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE 0 tJ
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date