HomeMy Public PortalAbout5956 ENCINITA AVE_Building__ ,. :WORKERS,COMPENSATION DECLARATION _ - i• ) r '• .
_. I herdb affirm that I hove a certificate of consent to self //p�� O O //p�� M I��} I��y D M
insure, or a certificate of Workers' Compensation Insurance, APPUCA"IrM l _Il OU�1 ����D�UV� �IS IIULI T7❑��
certified<opylhereof (Sec 3800, Lob. C.)
. a - _ COUNTY OF LOS ANGELES BUILDING AND SAFETY '
Policy.No. • Company- 9 - -- - - ' - " - - - -• -
BUILDING
❑v. Certified,copy is hereby furnished.. - FOR APPLICANT TO FILL IN �j- 5{p A( r'NGivi7 1
ADDRE55-
Certified copy is filed'with the county building inspec-' BUILDINGr
tion department. ' ADDRESS !C.14 C-IAII /9' ry x, t
Datev'.Applicant, •• CITY 7�H1 ZIP O fJ LOCALITY '
` CERTIFICATE OF EXEMPTION FROM WORKERS' - - O. OFIBLDGS. : - NEAREST•
--COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT I CROSS ST. Q ZR 2�/: ,-
(This section-need'not be completed if the permit is for one TRACT BLOCK LOT NO. -' ASSESSOR -hundred dollars ($100)or less.,), TELMAP BOOK PAGE PARCEL
_ NO USE ZONE MAP ,
•u. OWNER" N NO: V 3X '
Itcertlfy that in the performance of,ihe work for whicli,this NO. 2 Q 0 }
permit Is Issued, I shall not employ any person in anymaoner __ - /r��_ SPECIAL
so as to become subject to the Work s"Compensation Laws. ADDRESS pc( ."'fir(/ - -- - (\ CONDITIONS O
� V
aTY- Tz L . C -I/ _ zip 417£Y`J_ -i -- - -_ . •. - -- -.-. tie
Dd Ap'plica ARCHITECT OR
NOTICE O' LICANT: If,*of oking this Certificate o ENGINEER NO. DISTRICT- ,GRD P TYPE _ FlRE PROCESSED.BV t0
Exemp ori, 'you should become subject' td the'`Workers' CONST.' ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS y
with comply with. such,provisions or this permit shall be - - - - TEL. - STATISTICAL CU+S IF ATION y qPT. CONDO. #A
deemed revoked.• ., r, CONTRACT NO.
LICENSED CONTRACTORS DECLARATION .-, - - � -� V - - - LIC_ - -- 7 CLASS NO. DWELL'UNITS— '
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and _ - _ - _. LIC, _ _ SEWER MAP 1 •'J.•
Professions Code, and my license is in full force and effect. CITY CLASS 'BK - _ 1'PG
VALIDATION -
-_ SO. FT. NO 0F NO.OF._ CHECK ,
License Number Lia Class - SIZE - STORIES FAMILIES ONE VALUATION.
r
DESCRIPTION OF WORKS NEW - --
Contractor Date S 3 OOH
ADD ❑ D
1 am exempt under Sec. - - -- - - '_❑ - --
t
t , q .. , , . I ALTER t -
B.BP.C. for this reason _ - REPAIR ❑ '$
Date: - - USE OF.
EXISTING BLDG. DEMOL ❑ - -
APPLICANT TEL. x'2.1.Q 9 A
-Signature O FINA ,
OWNER-BUILDER DECLARATION PRINT N
I hereb affirmfhat.l�am exempt from the Contractor's License - - ' '# • • • •'•
Y P -
Law for the following reason (Section 7031.5, Business and ADDRESS 5q 56 /(/ A/G/.T// FI -'
J -Professions'Code):' ' - - ' - --- E N - B 11 • 59.'-25.
BUIL
I, as owner of theproperty, or my em to ees with ADDRESS S , _
_ o _ � - Px ADDRE., - ._ . _ - rS i • • 08985
wages ct their sole compensation, will f o the work and LOCALITY D �I
the structure is not intended or offered sale(Section \-� r ` „O �2 _ �
-7044;'Business and Professions•Code).- - - ` -' MOVING— - - TEL. - -"• - "- - - -
❑ 1, as owner of the property, am exclusively contracting CONTRACTOR
with licensed contractors to construct the project (Sec- - ADDRESS ,
tion 7044, Business and Professions Code).
`-
CONSTRUCTION LENDING AGENCY - SET BACK YARD -HWY TOTA PROP.AIME WIDTH of ?�! f -
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 1 '
P.L.
m Lender's Name -
LDMA Ref.'# t
- - - - - - - P.C.fee b - - - Permit Fee - - • f
- Lender's Address - '
I certify that 1 have.r¢ad this application and stale.that.the .. Issuance Fee TDMA P/C# -
a' above information is correct. 1 agree to comply with all County Investigation Fee
g ,ordinances and State laws relating to building construction _
� and hereby outhorize representatives of this County to enter - Total Fee-- x iDconstruction, -
$ up t is bove-mention d property for in ection purposes. -
w" SEE REVERSE FOR EXPLANATORY LANGUAGE ,
- Signature of Applico t or Agent - -- Dat •- - • - - - _ _ ._ ... . . .. .. _ _ _ 'fir
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