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Home My Public Portal About5825 ENCINITA AVE_Building__ j ^' y WORKERS' COMPENSATION DECLARATION `I'hereby affirm that I have a certificate of consent to self //L�L� O O fps �/(� ///�� L�L��FL� p} 1p�y �r�K� 1p' M�/[�� PER �Fp��p/L�� ipso;e,�lro certificate of Workers' Compensation Insurance, (r F,FL9Cy(r 1HQ V U OpR IJURM VG PLSLIOIE T or a certified copy thereof (Sec. 3800, L C.) - ' - °6 ' S* \S . // - �COUNTY.OF LOS ANGELES - BUILDING AND SAFETY Policy No./ Company — `,ILJI� ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING CFor i ADDRESS J ❑ Certified copy is filed with the county building inspec- BUILDING t f tion department. ADDRESS l �J Dale-L Applicant CITY I 7 ZIP LOCALITY (/ , 7 C– r CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF OT NEAREST L COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS Si. (This section need not be completed if the permit is for'one TRACT I BLOCK LOT NO. ASSESSOR hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL TEL USE NE MAP I certify that in the performance of the work for which this OWNER NO. NO permit is issued, I shall not employ any person in any manner ADDRESS I i SPECIAL so as to become subject to the Workers'Compensation Laws. ry CONDITIONS CITY p ZIP Date Applicant . NOTICE TO APPLICANT: If, offer making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP I TYPE FIRE PROCESSED BY Exemption, you should become subject to the Workers' ENGINEER NO. CONST. ZONE S �)<n / Compensation provisions of the Labor Cade, you must forth- ADDRESS I E \ V with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. DO. deemed revoked. CONTRACTOR N l LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS (commencing with Section 7000)of Division 3 of the Business and [IC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK. G PG. VALIDATION y SO. FT. NO. OF NO.OF CHECK d License Number Lic.Class SIZE STORIES FAMILIES ONE QQ VALUATION U Contractor L' r Dale DESCRIPTION OF WORK DD ❑❑ $ O ❑ 1 am exempt under Sec ALTER LU ❑ - > tI- - - .B.BP.C. for this reason REPAIR ❑ $ d' Date: USE OF _ DEM N EXISTING BLDG. 1nn n Z APPLICANT TE ;21 1'V.2 A Signature PRINT FINAL L" ? ,# 1 OWNER-BUILDERDECLARATION - DATE ,/ '-' JJ e e ev e• I hereby affirm that I am exempt from the Contractors License - Low for the following reason (Section 7031.5, Business and ADDRESS Ito FINAL Professions Code): PRESENT BY ( e e 6,0 5 0 ❑ BUILDING ' 1, as owner of the property, or my employees with ADDRESS r' • • • 6 0 5 0 wages as their sole compensation,will do the work and D - the structure is not intended ar offered for sale(Section LOCALITY -7044, Business and Professions Code). MOVING TEL. ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). -. CONSTRUCTION LENDING AGENCY SEO BACK YARD HWV TOTA VROPALINE WIDTH _ I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.I. Lender's Name LDMA Ref. p m Lender's Address P.C. Fee E Permit Fee 1 1 certify that 1 have read this application and state that the Issuance Fee .J LDMA P/C M above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, total Fee �s�'S IDMA Perm. M and hereby authorize representatives of this County to enter up p the above-mentioned property for inspection purposes. •' � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dote _ WORKERS' COMPENSATION D@}CLARATION - �I 'I sure, a,a certificate 1ho11 haver ce' Compensation consent to self �p��1��®�.II 'F®R B ROD'HNG PERM 7T1 �Ilull insure, or a certificate of Workers' Compensation Insurance, e.-4� u �V+ {� u�u u pr a�:ertified copy thereof (Sec. 3600, Lab. C.) - y' _ COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company T$ o��4 'FtJ$�'PErkE �� ,� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55U (} v A(A PIA Certified.copy is filed with the county building inspec- BUILDING I _ ' lion department. ADDRES r G�, Date . ; I Applicant $9�+aN`-'^T`^+", "'v CITY —' ZIP C.t Q LOCALITY O. OF BLDGS. NEAREST t COMPENSATION INSURANCE SIZE OF l01 — Z (WOW ON LOT CROSS CERTIFICATE OF EXEMPTION FROM WORKERS' ST. - N (This section need not be completed if the permit is for one _ ASSESSOR d hundred dollars ($100)or less.) TRACT 1— BLOCK - LOT NO. MAP BOOK U PAGE' 1 PARCEL I� TE}.� USE Z E MAP ^ - r OWNER n1 -13 •T' a'C I certify that'in the perforrnance'of the work for which this O. - permit is issued, I shall not employ any person in any manner C ( SPECIAL > � ' ADDRESS C--✓ lJ CONDITIONS Q so as to become subject to the Workers'Compensation Lows. �_ -C.L�.�"� O. I/ .. 11 U atr 0 zip � Date - Applicant '- ARCHITECTJ: TEt �p� NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER 'L/� N LQ�3Z DISTRICT I GRpUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' [ [� �� /) CONST./ ZONE W Compensation.provisions of the Labor/Code, you must forth- ADDRESS .SOU b - St 7G(� .J with comply with such provisions�'r this permit shall be _ ry _611 D. deemed revoked. 0` k / STATISTICAL LA IN TION APT. CONDO. Fn CONTRACTOR NO:. % Z J LICENSED CONTRACTORS DECLARATION 'UC. ' CLASS NO. DWELL UNITS_ ,`,\fit hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. _ ;1 (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP " Professions Code, and my license is in full force and effect. CITY CLASS BK LpG AillicolmiN2 3 SU SQ. FT�a ONO. OF NO.OF CHECK NI License Number 51 O!1 1 `Lit.Class 11 SIZE aWl STORIES ''-1/ FAMILIES ONE - J -•.58-1,40_. . ((yy p �-/�� NEW VALI(AT ON Contractor 1LIdP' fJ taluiZz."J Date._ DESCR PTID DF WORK ° DD ❑ $, ((J/" ' �� r.i e e 5 81.4 O c�.t I am exempt under Sec. '� '� I--t D ACCT A V p ALTER t_! �. �`O U'�8 8 B.BP.C. for this reason REPAIR ri' $• - 3307 1• 34.43 USE OF U. �. - Dote: EXISTING BLDG. DEMOI ''-+ : 1 ITEM$• r APPLICANT " .� Ti.ITAL - .]4.v.4'3_ Signature FINAL I PRINT OWNER-BUILDER DECLARATION F)'v RdD �� - ,DATE hereby the follow I g r exempt from the Contractor's License ADDRESS 'D FINAL / CHECKT 34.43 Low for the following reason (Section 7031.5, Business and 'i - . ... Professions Code): R ILD - BY CHANGE. .011 BUING - I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY - . nlArtn_llfl0i, y/31�89 7044, Business and Professions Code). MOVING TEL. OCONTRACTOR NO. -5425 1 AM11:36 I, as owner of the properly, am exclusively contracting t with licensed contractors to construct the project (Sec- 1' tion 7044, Business and Professions Code). ADDRESS ' CONSTRUCTION'LENDING AGENCY SET BACK - PROP.AINE WIDTH ' ^1�,. - REQUIRED YARD HWY TOTAL SETBA K ° s t.l ACCT.: t I hereby affirm that there is a construction lending agency for FRONT re the performance of the work for which this permit is issued _ P.L: X3307 735.130 (Sec. 3097, Civ. C.). SIDE Lender's Nome - $ P.C. Fee$ Per Fee �� LDMA of. R TOTAL 735-�DID Lender's Address CHECK - 735.00 aboveinformations c ad this application and state that the _ Issuance Fee r`�� LDMA P/C Is ? correct. I agree to comply with all County Investigation Fee CHANGE - .00 ordinances and State laws relating to building construction, 9 ,-� Total Fee O'0 - LDMA.Perm. R $ , and hereby authorize representatives of this County to enter ... . upon the abo e-mentio red property for inspection purposes. 0000-0001 8/31%84' SEE REVERSE FOR EXPLANATORY LANGUAGE Sig tura o1 A plicont or Agent Dole 5426 1 AM11:37