HomeMy Public PortalAbout6333 ENCINITA AVE_Building__ WORKERS' COMPENSATION DECLARATION
iffirm that I hove a certificate of consent to self' //& D O FII1 � ��//((�� //p�� �Lp�II7� FOR
�r��( M I(G I��v E��}�F��L•�/��L�
certificate of Workers' Compensation Insurance, lrp��Ls�`�j/rs1��O11 V Il OOYI L�J���D�U V\/ 0 LS UY10011��
_ copy thereof (Sec. 3800, Lab. C.) - COUNTY OF LOS ANGELES BUILDING AND SAFETY
1' p Company //
❑
If,
copy is hereBy furnilihed. - - FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUaw ] l ,•
tion department. ADDRoESSG � .J O
,
Date z / Applicant CITY ZIP LOCALITY
No. OF LOT NEAREST � / tQ
ERTIFICCOMPE COMPENSATION
IO FROM ORKERS' SIZE OF LOT NOW ON LOT CROSS ST.- C-', 1 I 1
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for,one - TRACT ' BLOCK TOT NO, "- MAP BOOK PAGE PARCEL
'hundred dollars ($100) or less.) TEL.
OWNER - - USE ONE MAP
1 certify that in the performance of the work forwliich this
NO. / �•w
permit is issued, I shall not employ ony.person in any manner ADDRESS - SPECIALCONDITIONS
-
so alto become subject to the Workers'Compensation lows. / O
_ CITY !-/ - -ZIP U
Date Applicant 'ARCHITECT OR TEL. -
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER. NO. DISTRICT. GROUP TYPE _ .FIRE ROCESSED BY
CONST. ZONE /� �• U
Exemption, you should become -subject to the Workers' Ls O 7( Q 1 _ /•'y( W
Compensationprovisions of the Labor Code, you must forth. ADDRESS ' r /l 1• 7 I o-
STATISTICAL CLASSIFICATION APT. CONDO. N
with comply with such provisions or this permit shall be TEL. Z
deemed revoked. - CONTRACTOR NOZ�Z_S
LICENSED CONTRACTORS DECLARATION LIC. - CLASS NO. . DWELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter-9ADDRESS N�• T t x
(commencing with Section 7000)of Division 3 of the.Business �jl _ �r LIC. /] SEWER MAP
and Professions Code,and my license is in full force and effect. CITY �✓ c-c�C_ CLASS /7 BK ✓ VALIDATION
SO. FT. - NO. OF NO.OF CHECK l-•
License Number Zr `)^-1 �� Lic Class SIZE STORIES FAMILIES ONE
- -
VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑ S� /��, dQ
'�_ ADD' D: (iC� D
Elam exempt under Sec ALTER ❑ - -
• B.BP.C. for this reasonREPAIR EJ
6
Date: USE OF _ .. _ ..
EXISTING BLDG. DEMOL'❑
Signature APPLICANT - TEL.
OWNER-BUILDER DECLARATION (PRINT) NO. -_-, - FINAL /,
I %U
I hereby affirm that I am exempt from the Contractor's License :. DATE
Low for the following reason (Section 7031.5, Business and ADDRESS' - FI _
Professions Code): PRESENT BUILDING
- y -
8
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and 59.25
7044,
the structure is not intended or offered for sale(Section LOCALITY _ D�. '-t 1 3 L307 - 59. 25
7044, Business and Professions Code.) MOVING TELr�:�i T� i T"��
❑ I, as owner of the property;,am exclusively contracting CONTRACTOR NO, j( Lyxc/ t`� _ . 1 -
with licensed contractors to construct the project (Seo- ADDRESS - - "X- - ;, i ' s TOTAL 59 . 75
tion 7044, Business and Professions Code.) - _�
REQUIRED TOTAL SETBACK FROM EXIST.:• �,t �• r ' tC:HECK 59.'x`5
CONSTRUCTION LENDING AGENCY SET BACK YARD -HWY PROP.'LINE WIDTH ' �,
I hereby affirm that there is a construction lending agency for FRONT r; �_: -t _ CHANE
the performance of the work for which this permit is issued " P.L.
(Sec. 3097, Civ. C.). SIDE - - '..s '
P.L. S '
Lender's Nome S• t, ..C • Q(f�l-CI(UJ1 v774{39
$ P:C. Fee $ - - _ Permit Fee 'CDMA Raf. q' 0276 I � 8:51-
Lender's Address - � 1
o I certify that I have r d this application and state that the Issuance Fee 16"5,01 LDMA P/C q D
$ above information is rrect. agree to comply with all County Investigation Fee
ordinances and St t laws relating to building construction, - Total Fee . CDMA Perm. q
a and hereb tF� representatives of this County to enter
upon th o - ro erty-for inspectio purpo/es. -
,. J -Z SEE REVERSE FOR EXPLANATORY LANGUAGE
SignaWre of Applicant or Agent Date ,