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Home My Public Portal About6002 ENCINITA AVE_Miscellaneous__ WORKERS'COMPENSATIONDECLARATION CE 875 (2-80) MISCELLANEOUS APPLICATION CE 8]5 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 IN BUrLp REDr N55 G o pD ❑ Certified copy is hereby furnished. BCND_'G ^ IVE .ter LOCALITY ADDR=_ss 6 l ❑ Certified copy is filed with the county building inspection �� NEAR Esr department. LOCALITY + cRoss sr. Date Applicant NEAREST DIa TRIC NO. 1 GRO P TYPE ESSEp BY CROSS ST. �� CONST. -- CERTII'ICATE OF EXEMPTION FROM WORKERS' - LEGAL COMPENSATION INSURANCE DEsc RIPnoN LOT rvo. G BLocK .+oP „IG�w. .... Lc) STATE MAJOR SECOND LOCAL } NO. OF BLDGS. 0 (This section need not be completed if the Work involved TRACT NOW ON LOT USE ZONE SPE CTAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) - i 05E of U SI2E OF LOT _fo 144, EXISTING BLDG. -1 certify that in the performance of the work for which this Al permit is issued, I shall not employ any person in any manner OWNER 0 so as to become subject to the Workers' Compensation Laws. MAIL16W OCC UPANCV GROUP U W ADDRE SS IL Date Applicant to EL. NOTICE TO APPLICANT: If, after making this Certificate of elrY rvo. JA OCCUPANT LOAD Z_ Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit Shall he TRAILER USE[] GEOLOGY INSPECTIONNo Spec. Knowl. ❑ deemed revoked. t LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions Of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000) of Division 3 of the Busi- ntVs and Professions Code, and my license is in full force and PARKING. effect. SPACES REO'D PROMO EO 11 `cense Number Lic.Class LIMITED TIME USE - Contractor Date RDM:� T G I am exempt from.The licensing requirements as I am a. INSPEC OR'S licensed architect or a registered professional engineer 512E OF NO. OF �y �Lr�f L_.L��I / acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES sIGNp Uh E, mess and Professions Code . P ) PRESENT USE OF BUILDING FINALA ROVAL Lie.or Reg.No. Date V HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 3 5,3,6rA-'. ON LOT AND VSE #'0I . . 30 I hereby affirm that I am exempt from the Contractor's ' I License Law for the-following reason (Section 7031.5, Busi- I _ ,2-• j, o.,y5 = ness and Professions Code): 'ND. PARKNG 'o:e.o (,l0 SPACES PROVIDEDN 'oIq O ❑ I, as owner of the property, will do the work and the structure is not intended or offered,for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I herebyaffirm that there is a construction lending agency for the performance of the work for which this permit is ' issued (Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the - above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction. TOTAL FEE c_ v and hereby authorize representatives of this County to enter upon t e above-Tentioned ropert for ' pection purposes SEIi REVERSE hOR EXPLANATORY LANGUAGE Signature of PermitTee e Da .i4.4QR.IC_ S'.CUMPENSATION DECLARATION 76M444- F CE 875(11-84) MISCELLANEOUS APPLICATION I 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 certied copy thereof(Sec. 3800, Lab.C.). _ PolicyNo. Company BUILDING - , P FOR APPLICANT TO FILL IN _ ADDRESS Certified copy is hereby furnished. BUILDING + LOCALITY J ADDR EES Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS sr. Date Applicant NEAREST 1. . /) DISTRI nT P E By CR055 ST. w V C. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DescRlPn ory Lor No. BLocK C. NOOF LOGS. x0. (CIF CLE) TATE MAI R ECOND LOCAL . (This section need not be completed If the WOIk InVO1VEd TRACT NOW ONBLOT USEZONE SPECIAL CONDITIONS by the permit is for one hundred deltas ($100) or less.) US OF SIZE OF LOT EXISTING BLDG. Y 1 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 L Tyr so as to become subject to the Workers' Compensation Laws. MAIL /`s _ OCCUPANCY GROUP m ADOR E55 ��V �� • O Date Applicant TEL. W NOTICE TC APPLICANT: If, after making this Certificate of CITY OCCUPANT LOAD O- Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE E] GEOLOGY INSPECTION No Spec. KnoWl, deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices E I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (41ST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- No. of Exlrs ness.and Professions Code, and my license is in full force and ,{ { �I /�� effect, (/ ��J {J-C,�•�- PARKING REOD pROVIO ED SPACES License Number Lic. Class III if LIMITED TIME USE Contractor Date DATE DATE D1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF No, of INSP Cro R's acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. _ sroR.Es SJqNATURE iness and Professions Code). PRESENT USE OF BUILDING L? FINAL APPROVAL Lic.Or Reg.No. Date i HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS (�I� ON LOT AND USE 1•rr r.•I.T --I hereby affirm that I am exempt from the Contractor's CC _ License Law for the following reason (Section 7031.5, Busi- 3?07 40.50 ness and Professions Code): NO.PARKING I, as owner of the property, will do the work and the SPACES PROVIDED 1,ITEMS structure is not intended or offered for sale (Section T`}T� II_�F.J �- �� 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING 0CN(.r C CHECK - 80.50 I hereby affirm that there is a construction lending agency CHANGE ; Xil for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name 0000-0001 5/17/'9 PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE p 0 k337 -1 AM 31:56 above information is correct. I agree to comply with all County ISSUANCE FEE C) jp ' ordinances and State laws relating to building construction, and hereby luthorize repres atives of this County to enter TOTAL FEE i7 upon the {e-me boned perty for inspection purposes. (/ / r / SEE REVERSE FOR EXPLANATORY LANGUAGE S- tur VAI Per ttee / ate