HomeMy Public PortalAbout6324 ENCINITA AVE_Building__ • / COUNTY OF LOS ANGELES BUILDING AND SAFETY � • • LLLIII
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN - ,ByILD/ANG ADDR�E/gs .a '
1 hereby affirm that I have a certificate of consent to sell insure, BUILDING ADDRESS y: �4 I
or a certificate of Workers'Compensation Insurance,or a certified I� Avenue
copy thereof (Sec.3800,Lab.C.) - C remp l e City ZIP 91780
t7II0 LOCALITY
Polity No. Company SIZE OF LOT - NO.OF SLOGS.NOW ON LOT ti `•
❑ Certified copy is hereby furnished. S Q. Ft. One NEAREST CROSS ST. '
❑ Certified.copy is filed with the county building inspection TRACT BLOCK LOT NO. '
department
USE ZONE MAP N0.
ASSESSOR P BOOK PAGE PARCEL
Date Applicant • jjg �/ 7 033 SPECIAL CONDITIONS-
CERTIFICATE OF EXEMPTION'FROM WORKERS' !!!��� OVER i n i to Trust (`8`119')287-6092 YES No
COMPENSATION INSURANCE - WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is to, one hundred ADDRESS
dollars ($100)or less.) \\ 1 DISTRICT GROUP TYPE CONST FIRE ZONE �PR�OCESSED BY
V CI V ZIP I certify that in the performance of the work for Which this permit §an Marino 91108 0 �j 1 � G�
i5 issued, shall not employ any p n in anymanner so as to �• G
become subject to the WOrken CO eOSati00 Laws. ARCHITECT OR ENGINEER TEL NO. - _
Jan. 3p ad��� Associates] 818 288-1216 STATISTICAL CLASSIFCATION APT CONDO
Date q CLASS NO. n DWELL UNITS /
��+W N. San Gabriel Blvd. O S. G.
NOTICE TO APPLICANT: If, after making this Certificate -of r REQUIRED TOTAL qFt&hIdRRrDM EXIST
Exemption, you should become subject t0 the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP,.;) � WIDTH
Compensation provisions of the Labor Code, you must forthwith FRONT " u"� IF S 1 ,: 7 .11
comply with such provisions or this permit shall be deemed revoked. DDRESS LIC.NO. - P L 2 n
LICENSED CONTRACTORS DECLARATIONSIDE
• CATV LIC.CLASS
hereby affirm that,l am licensed untlerprovisions of Chapter 9 SEWER MAP G T>. _ ,• �,11,,,
(commencing with Section 7000)of Division 3 of the Business and SO FT 512E NO.OF STORIES NO,OF FAMIUES CHANGE
Professions Code,and my license is in full force and effect. 3 421 It One NEW X] BK PG D •0
' License Number Lie.Class, DESCRIPTION OF WORK - ADD ❑ VALUATION yy « C.)
LEI
I' Contractor Date $ a�/P DO e) _ O-
ALTER ❑ S fp 0701 173�/96ZO
❑ 1 am exempt under Sec. pa(O f l residence. REPAIR ❑ $ 624 1 PM12:3'M
BSP.C.for this reason DEMOL ❑ CDMA P/C 0
Date. y` USE OF EXISTING BLDG. URM ❑ '
Signature
APPLICANT(PRINT) SL NO LOMA Perm w `AC-CT g
❑ I, as owner of the property, or my employees with wages as t 8)287-6092 ^ _ - .a
their sole compensation;will do the work and the structure is J ADDRESS - - O 330 ^ 2646 3Q
'not intended or offered for sale (Section 7044, Business and 1 'FINAL DATE Q p •'1 ITEMS
Professions Code.) H ,n O 1�
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL //.�•Z _
J\ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EOUAL TO OR GREATER THAN THE J ( 2646.30
❑ I, en owner Of the property, am the O1VQIy COOI(aChng with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL By j 7i TFlL
licensed contractors to construct the project !Section 704 LA](
Business and Professions Code.) � vEs❑ No I � "� C:F{E(:Yi 2646.00
WILL THE INTENDED USE OF THE BUIDWUG BY THE APPLICANT OR FUTURE BUILDING v i,N
IF
CONSTRUCTION LENDING AGENCY Jt OCCUPANT REOURE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
AIR OUPUTW MANAGEMENT DISTRICT ISCAOMDI SEEEE PERCHANGE
PERMITTING CHECttUei FOR ! J.
1 L
GUIDEUNEs ,,yy •
I hereby affirm that there is a construction lending agency for YES C1 Nom
the performance of the work for which this permit is issued(Sec.
PERMITTING P HAVE READ HAZARDOUS INFORMATION AND Oti
`
, 0071
3097,Civ.C.) CHECKLIST.I UNDERSTAND MY EOUIREMENTUNDER THE LOS ANGELES COUNTYCODE, c/ O 6/96 96
Lenders Name TITLE 2.CHAPTER 220 SECTIONS 220
100 THROUGH 220 0 CONCERNING HAZARDOUS 6316 1 FM 5.41
MATERALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMO
Lender's Address aPOP.wLN -
I certify that I have read this application and state under penalty
B. of perjury that the above information is correct.I agree to comply PC.FEE } L� PERMIT FEE
mA with I1 county ordinances and State laws relating to building �`//�' / �� /•
m cons fiction, and hereby authorize representatives of this County ISSUANCE FEE y,(
O toe Upon thea entioned property for ins L a /. O f
g �p ✓�N INVESTIGATION FEE TOTAL FEE
SEE REVERSE FOR EXPLANATORY.LANGUAGE