HomeMy Public PortalAbout6254 ENCINITA AVE_Miscellaneous__ r.-_.\VORKERS'COAIPENSATION DECLARATION
CE 875 MISCELLANEOUS APPLICATION
ys It t-eat L, I
I hereby affirm that 1 have a certificateof consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION lul
insure, or a certificate of Workers's'Compensation nsation Insutatice,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILD]HG
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Certified copy is hereby Furnished. BUILDING ADDRESS
5112 Halifax Rd
ADDRESS LOCALITY /J
DCertified copy is filed with the county building inspection LOCALITY NEAREST L-
department. Temple City, Ca. 91780cRoss ST.
Date Applicant NEAREST OISTR ICT O OUP TYPE—' PRO ESSED BY
CROSS ST. t �� — CONST. 1
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL �(
COMPENSATION INSURANCE DESCRIPTION Ill LOT NO, BLOCK STATE MAIOR SE CO NO LO L
NO.. (C, CLHI
NO. OF BLOGS.
(This section need not be completed If the work involved TRACT v NOW ON LOT VSE ZONE SPECIALCONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
SIZE OF LOT EXISTING BLDG. �� ,
1 certify that in the performance of the work for which this y o
l F
permit is issued, I shall not employ any person in any manner OWNER Nader and Debo rah Menh d' '
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o
ADDRESS
Date Applicant 5112 Halifax w
NOTICE TO APPLICANT: If, after making this Certificate ofcITY Temple C1t NOL H1H 57S-3859 OCCUPANT LOAD D_
Exemption, you should become subject Workers- APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,, youu must forth-
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Kk Panic Devices
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 EXITS
ness and Professions Code, and my license is in full force and
effect. PARKING
SPACES REO'. PROVIDED
License Number Lie. Class
LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. of ' E R•s
SIG T RE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 1
iness and Professions Code).
PRESENT USE OF BUILDING residence FINAL APPROVAL
Lie.or Reg. No. Date '
s )
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE 1 residence
1 hereby affirm that 7 am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
0 1, as owner of the property, will do the work and the SFACES PROVIDED 2
structure is not intended or offered for sale (Section ,
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING living area
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is ` t
issued(Sec. 3097,Civ.Q. 1
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
I certify that 1 have read this application and state that the
above informal correct. I agree to comply with all County ISSUANCE FEE
ordinances and S o building construction,
an hereby auth riz res ives f this County to enter TOTAL FEE
u the a v ¢trt o inspectio purp ses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signal of Pernt D e