HomeMy Public PortalAbout5942 ENCINITA AVE_Building__ IlWORKERS'COMPENSATION DECLARATIOIG '
Thereby affirm that I have a certificate of consent to self Qp.� �A� 0 BU�d��NI P° ERMOT
insure, ora certificate of Workers'Compen nlnsurt to s if \
a certified copy thereof (Sec. 3800, p� � �G COUNTY OF LOS ANGELEO.( , BUILDING AND SAFETY
Policy No. Company L�Z&� / •
Certified copy is hereby furnish I F PPL ANT TO FILL IN • BUILD WG
ADDRESS
Certified copy is filed with the unt ui mg ins BUILDING njO` �w�G
tion department. ADDRESS LOCALITY
NEAREST 7
'Date -' Applicant _ CITY ./�pL� ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' '7 NO. OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT d �/ NOW ON LOT MAP BOOK PAGE ARCEL
(This section•need not be completed,if the permit is for one USE ZONE MAP G� 7
.hundred dollars ($100) or less.) TRACT BLOCK LOL NO. NO. }
L. Q �q-Tl[ SPECIAL d
OWNER — 17-1 /`� NTEOLX/0— / CONDITIONS O
I certify that in the performance of the work for which this DISTRICT GROUP TYPE FIRE R SEED BY
permit is issued, I.shall not employ any person in any manner �j�i�`��J/r CONS . V
^
so as to become subjectADDRESS to the Workers'Compensation Laws. / /l� C(/e / OC
Date / ' Applicant �' r CITY �� %/ 'ZIP STATISTICAL CLASSIFICATION APT. - CONDOz U
NOTICE TO APPLICANT: If; after making this ertificate of ARCHITECT OR - �(%�/JLt NLo.,�� i/' /7 W
ENGINEER �C 7z� DWELL. UNITS_ 6
Exemption,•you should become subject to the Workers' �j CLASS NOGY N
Compensation provisions of the Labor Code, you must forth- ADDRESS SWER P
with comply with such provisions or this permit shall be TEL •� J` .
deemed revoked. CONTRACTOR � S NO. B PG, VALIDATION
LICENSED CONTRACTORS DECLARATION p� /� LIC. c�
I hereby affirm that I am licensed under provisions of Chapter 9 - , ADDRESS ��O LU/'CC�I�' NO. 'f.2/I�7 VALUATION -
(commencing with Section 7000)of Division 3 of the Business and / LIC.
Professions Code, and my license its in full force andel effect. CITY �L' CLASS $
22 /U/ Li0.Class % SO. FT,q�r 5ORLEES AMILIES CHECK
License Num/berms L SIZE 7 7 DESCRIPTION OF WORK
Contractor C-C/ /Date t ��aG�
� - ❑ $ .
1 am exempt from the licensing requirements as I am a *7;12:�` ADD
licensed architect or a registered professional engineer ALTER ❑ FINALDATE
A
acting in my professional capacity (Section 7051, REPAIR ❑ 1 U
Business and ProfessionsCode), USE OF L DEMOFINAL
EXISTINGEXISTIN :; ''
2 0'6 4,8 A
Lic.or Reg. No. Date APPLICANT TEL.
OWNER-BUILDER DECLARATION (PRINT) - 1�y) �� //�L,.�NO 77/J �� _/� - /f # e•°
1 hereby affirm that I am exempt from the Contractor's License ADDRESS �E/'�c.�i (21i �_C�/1JY'�"�l 2 °.1 5 1,0 0
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT
❑ BUILDING ° ° ;5 1,00 5
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and O 8.10 5—8
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
I, as owner of the property, am exclusively contracting CONTRACTOR NO. '
with licensed contractors to construct the project (Sec- - ADDRESS
tion 7044, Business and Professions Cade). .
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWV PROP, LINE WIDTH
-1 hereby affirm that there is a construction lending agency for FRONT.
the performance of the work for which this permit is issued PA
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name '
P.C. Fee S Permit Fee /
Lender's Address
w I certify that I have read this application and state that the Issuance Fee
a above information is correct. 1 agree to comply with all County _ Investigation Fee /
aordinances and State laws relating to building construction,
m and hereby authorize representatives of this County to enter Total Fee _
vr upo the above-mentis d proper y for inspection purposes.
.i
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o0plicionATKen, Dote - �r