HomeMy Public PortalAbout6018 ENCINITA AVE_Miscellaneous__ R'ORKERS'COMPENSATION DECLARATION
CE 875 (11-64) LJ
MISCELLANEOUS APPLICATION {�
CE 875
I hereby affirm that 1 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 BUILDING
ODRESS
Certified copy ishereby furnished. BUILD I"° O �• C- Lo cw ury
ADDRESS
Certified copy is filed with the county building inspection LOCALITYNEAREST
department, p CROSS sr.
Date Applicant NEAREST DISTRICT NV GROUP CONST.
CROSS ST. Com' S G v
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTaory LOT NO. — o awcK iD�ww
NO (CIA CLE) STATE MAJOR SECO LOCAL
NO, OF BLDG.,
(This section need not be completed if the work involved TRACT �� NOW ON LOT Z VS 20NE .PE CIwL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
SIZE OF LOT 5 F EXISTING BLDG. �I d
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 ai bf SC • �2 ='
so as to become subject to the Workers' Compensation Laws. MAIL _ .00CUPANCY GROUP Lam- �; J o
'
ADORE - r ,, , \. -'\'
DateApplicant Lno
TEL. .C• OCCUPANT LOAD 0-
NOTICE TO APPLICANT: If, after making this Certificate of CITY �; r F - NO. 3 C y�07 p o_
Exemption, you should become subject to the Workers' APPLAATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must.forth-
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION No Spec. Knout . Eldeemed revoked. ❑ ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- No. of EXIT. El
ness and Professions Code, and my license is in full force and � n l
effect. t✓� -tom. aN� tn1�7 rI.ItAWv PARKING REQ'D' E:::= PROVIDED
SPACES
License Number Lic. Class ' 'n ¢ �/ LIMITED TIME USE
Contractor Date '-'(PYIi J 4 r2a oAT. DOTE
DI am exempt from the licensing requirements as I am a G�C+1 ell, ,
licensed architect or a registered professional engineer SIZE of No. OF INSPECTORS
g P g /
acting N my .professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI NATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING (/
Lic.or Reg.No, Date
HOME OWNER-BUILDER DECLARATION NO, of EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the<'following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING - I
j
I, as owner of the property, will do the work and the SPACES PROVIDED \
structure is not intended or offered for Sale (Section _' Sp-;] 3.3,A
7044,Business and Professions Code).
v ���
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING :?-� -
I hereby affirm that there is a construction lending agency
For the performance of the work for which this permit is e . .,.8 Q 5 O'LI
issued(Sec. 3097,Civ.C.).
Lender's Name ' 0 9.2 2-.8'8 .
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 C7
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upo t abov -menti p perty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Per ttee Date
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