HomeMy Public PortalAbout5827 ENCINITA AVE_Building__ _ WORKERS`COMPENSATION DECLARATION
l�hereb ofBrm'ihaf-I have a certificate of consent to self ART
�/(� //p�� �II��Ip� FOR
�F}�y,�` �FI��p��(/�� D 1��}�F��y��pL�@/LL�
insure, or a certificate of Workers' Compensation Insurance, +'"�''-vC ART P.L�CA Ir 0 O II V U 0110 ROMMMIG PLS IIgIIV 07
,ora certified copy thereof (Sec. 3800, Lab. C.) -
Policy o. Company
-CXN4'31[-(iiSOiscr- c— . COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. APPLICANT TO FILL IN BUILDING
ADDRESS
G--VCJP!iTA Alit--
Certified copy is filed with the county building inspec. BUILDING Q L 11
tion department. 1I�11'' L' 1I ADDRE 1 b `zl N GI
Date, 4\ -Applicant Sl i 4.�LjuyF r,%h CITV 1,F" ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDG . NAREST
COMPENSATION INSURANCE - SIZE OF LOT Y�jU2 �'�7/a NOW ON LOT CROSS
ST.ASSEU
(This section need not be completed if the permit is for one TRACT yfT J BLOCK LOT NO. MAP BOR ,q f Q' l
hundred dollars($100)or less.) - MAP BOOK PAG PARCEL 4..�
�- MAP �� ZCo
certify that in the performance of the work for which this OWNER USE ZONE
/,�J
permit is issued, I shall not employ any parson in any manner ADDRESS w� { IVK\ �Z SOt IAL / S
so as to become subject to the Workers'Compensation Laws. CONDITIONS
CITY L ZIP 76 U
Date Applicant ARCHITECT y-C,� T
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER. Vv�� N DISTRICT GROUP TYPE FIRE PR SSED BY Q
Exemption, you should become subject to the Workers' C CONST. ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS '
with comply with such provisions or this permit,shall - d
deemed revoked. CONTRACTOR NO. a STATISTICAL CLASSIFICATION y� APT. CONDO, N
LICENSED CONTRACTORS DECLARATION - CLASS NO._SL DWELL. UNITS-1--/• Z
I hereby affirm that I am licensed under provisions of Choptar 9 ADDRESS NO. SEWER MAP '
(commencing with Section 7000)of Division 3 of the Business and - LIC
Professions Code, and my license is In full force and effect: CITY CLASS BK [,_PG VALIDATION
t a
SQ. FT
I O STORIIEES 7� AMILOIES CHECK
License Number.�33Cn 1 LIc.Class fJ ,
/ ¢ VALUATION A 93 Q3 A
P°g'I
Contractor 1.110PI 1 2MPeJ Date S)I hd DESC IW f K NEW s
Gold ADD /. / # a . . e 2 3 .
I am exempt under Sec. -
AIiER ❑ - D. - ,I�:e.4;0 6�9 8
E.&P,C. for this reason - .REPAIR . f ._y.._._._ _... .21
Date: EXISTOING BLDG. t DEMOL ❑ ACCr;;& 4 0 6 9 8 UL
Signature APPLICANT ,\ T FINAL -ry- .. ... 33070 4,0 4�8 8 2T 11
PRINT N `/1
OWNER-BUILDER DECLARATION - DATE
I hereby affirm that I am exempt from the Contractor's License 1`ITEMS
Law for the following reason (Section 7031.5, Business and ADDRESS AS FINAL-
Professions Code): eY" r TOTAL- - 24. 11
❑ BUILDING Ij,,^
I, as owner of the property, or my employees with ADDRESS 'CHECK 24.11
wages as their sola compensation,will do the work and C
the structure is not intended or offered for sale(Section LOCALITY D 0
7044, Business and Professions Coda). MOVING - TEL
,
❑
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
atting ` I
with licensed contractors to construct the project (Sec- 1 f 1 s �jszs+o-�1
tion 7044, Business and Professions Code). ADDRESS " ; \,\ ' E131/809{
REQUIRED TOTAL SETBACK t 't k' 5427
CONSTRUCTION LENDING AGENCY SET BACK YARD HwY PROP. uNE wIDTM ', 1 AM11:39
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. y-
(Sec. 3097, Civ. C.). SIDE
P.I. .{Ill
Lender's Name ..
LDMA ReN 'v'
m P.C. Fee$ Permit tae t� r✓ V r' sap
Lender's Address �L
1.certify that I have read this application and state that the ♦// issuance Fee p C `7—V TDMA P/C A �.. ' 1 Eri
4 obov ,information is correct. I agree to comply with all County Inv vigation Fee C t� t V31
ordinances and State lows relating to building construction, Tatol Fee
Q and hereby authorize representatives of this County to enter d 6 - LDMA perm. N W
upon the above-mention d property for inspection purposes. \ ;
e,r
aljl SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa re of A ficont of Agent - Dote - W b •O spy, O