HomeMy Public PortalAbout5936 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 111-84) M ISCELLANEOUS APPLICATION
CE 675
1 hereby affirm that I have a certificate of consent to self 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.).
Policy No. Company FOR APPLICANT TO FILL INU
BILDING
ADDRESS
Certified copy is hereby famished. pops Ess �' Q ocA urY C.
ElCertified copy is Filed with the county building inspection LOCALITY J NEAREST
department. CROSS ST. S
Date Applicant NEAREST ' OIeroICT No OUP TYPE PROC $S'ED BY
CROSS ST. , O CONST.
CERTIFICATE OF EXEMPTION FROM WORKERSLEGAL
COMPENSATION INSURANCE DESCRIPnoN Lor No. eLo cKMAPICNwA
NOOF BLOCS. IC�w CLE) STATE MAJOR SECOND LOCAL
.
(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 ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. a
I certify that in the performance of the work for which this - o
permit is issued, I shall not employ any person in any manner OWNER ' 2
so as to become subject to the W kers' Comp nsatiol L 's. MAIL v A OCCUPANCY GROUP. ` .�,3 0
ADDRESS
kDate LCL/Appli
TEL' OCCUPANT LOAD
NOTICE TO APPLICAN . If, t making this Certificate of CITY - NO.
Exemption, you should becom ' subject to the Workers' APPLICATION F R 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 Chapter SAFETY PERMIT E-] (MST 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. Q G '� /' PARKING RE0D PROVIDED L
/� SPp CEg
License Number Lic. Class
� � LIMITED TIME USE
Contractor Date DATE DATE
1 am exempt from the licensing requirements as I am a _
licensed architect or a registered professional engineer S6E oP No. of In SPECTORE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNArUR
iness and Professions Code). - / C FINAL APPROVAL
PRESENT USE OF BUILDING Cf
Lic.or Reg. No. Date '
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 30
ON LOT AND USE
I hereby affirm that 1 am exempt from the Contractor's ACCT.4
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING 3307 I 80.50
L as owner of the property, will do the work and the SPACES PROVIDED 1 .ITEMS
structure is not intended or offered for sale (Section
7044,Business and Professions Code). l ' TOTALI ` '80. -50
CONSTRUCTION LENDING AGENCY PRoroseD USE OF BUILDING CHECK \ y 80.50
I hereby affirm that there is a construction lending agency •. \ :CHASE.. 00
for the performance of the work for which this permit is -
issued(Sec. 3097,Civ.C.). I ,
Lender's Name PROPOSED MAX. Dec. - , O01]O'0001 8 18/29
Lender's Address ,
, U
I certify that I have read this application and state that the PERMIT FEE 5164 1 AM 9.49
above information is correct. I agree to comply with all County ISSUANCE FEE J
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
up n tl a above-mention property 'nspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
/} nature of Permittee Date