HomeMy Public PortalAbout6021 ENCINITA AVE_Building__ WORKERS'COMPENSATION DECLARATION ",.;
Ii hereby affirm that I have certificate of consent to ,elf WPUCA760N FOR BMpdD5NC1� PERM07
insure, or a certificate of Workers' Compensation Insurance,
or a cent,Pied copy thereof (Sec. 3800, Lab. C. -
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDING 1 - r _
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 6p-)] 1K
❑ Certified copy is filed with the county building inspec- BUILDING
ADDRESS tion department. LOCALITY T
- A' e �i- NEAREST
Date Applicant. CITY P,-c C• ZIP !J� CRO555T. tit.l
. CERTIFICATE OF EXEMPTION FROM WORKERS' .OF BLDGS.- ` ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT• NOW ON LOT.'• MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one ,. - •t - USE ZONE MAP -
hundred dollars ($100)or less.) - TRACT . BLOCK LOT NO. NO.
- TEL.' SPECIAL }
OWNER NOipp CONDITIONS a
certify that in the performance of the work for which this DISTRICT .GROUP TYPE FIRE PR OC ED Y O
permit is issued, I shall not employ any person in any manner ADDRESS 7 7 n �i• CONST. - ZONE /ELS]/$/�)g' U
so as to,become subject to the Workers'Compensation Laws. f ' �. �� n` l..
I C
Date Applicant CITY C-leTOR E ZIP -G) O
ARCHITECT OR TEL STATISTICAL CLASSIFICATION APT, CONDO. L~.l
NOTICE TO APPLICANT: If, aftermaking this Certificate of ENGINEER NO. C1A55 NO.—al— a
Exemption, you should become subject to the Workers' . DWELL. UNITS_
Compensation provisions-of the Labor Code, you must forth- ADDRESS - SEWER MAP
with comply with such provisions or this permit shall. be TEL. ?
deemed revoked. CONTRACTOR NO.. BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION - LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION"
(commencing with Section 7000)of Division 3 of the Business and '^• LIC.
Professions Code, and my license is in full force and effect. CITY CLASS S ' o oD D
SQ. FT. NO.OF NO. OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
NEW S
Contractor Date DESCRIPTION OF WORK p ,
I am exempt under Sec.
YL/D� tl �'S�/c/� e ADD
ALTER FINAL 7�Z '�8 6 2.5 A
B.BP.C. for this reason t��7 REPAIR � DATE
Date:
USE OF DEMOL FINAL # a s e • • I
✓
EXISTING BLDG. � BY
Signature - + APPLICANT /� L. 2•^ - 4 9.88
OWNER-BUILDER DECLARATION - (PRINT)' a�rJ.f/DA tG o. B68r
I hereby affirm that I am exempt from the Contractor's License - D e e • 4 9.8 8
Law for the following reason (Section 7031.5, Business and ADDRESS
'Professions Code): PRESENT .12.28-82
+
UILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and - LOCALITY
the structure is not intended or offered for sale(Section
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 Code).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP. LINE WIDTH D
I hereby affirm that there is a construction lending agency for FRONT -
the performance of the work for which this.permit is issued PL.
(Sec. 3097, Civ. C.). - SIDE
P.L.
m Lender's Name -
Lender's Address P.C. Fee S Permit Fee f
I certify that I have rood this application and state that the Issuance Fee 10 •J `-'
Z 'above information is correct. I agree to comply with.all County Investigation Fee I _
9 ordinances and State laws relating to building construction, Total Fee
C and hereby authorize ffsentot*v Iof this County to enter
Upon the above-mentiproPP�or 4 for i spection purposes.—�/ SEE REVERSE FOR EXPLANATORY LANGUAGE
/ Signature of Applicant or Agent Dole ®r