HomeMy Public PortalAbout4919 KAUFFMAN AVE_Miscellaneous__ WORKER j'COMFtNSATION DECLARATION 76N1444 MISCELLANEOUS APPLICATION
I hereby affirm that I have certificate of consent to self' COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workea rs'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No.' Company - FOR APPLICANT TO FILL IN BUILDINGU4 te
ADDRESS T J..
❑ Certified copy is hereby furnished. AppRDING
LOCALITY'
❑. Certified copy is filed with the county building inspection NEAREST
department. LOCALITY CROSS ST. y
,Date -Applicant - NEAREST DISTRICT NO G UP TYPE PROCE 'BY
CROSS ST. �,' CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL t
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP /`/) HIGH WAV }
No: p / V(CIRCLE(- STATE MAJOR.SECOND 'OCAL a
NO. OF BLDGS.
(This section need not.be completed if the work involved TRACT NOW ON LOTUSE ZINE SPECIAL CONDITIONS'• O
by the 'permit is for one'hundred dollars ($100) or less.)
.USE OF JAI .cc
' SIZE OF LOT - 56 � EXISTING BLDG. I/
I certify that in the performance of the work for which this Q
permit is issued, I shall not employ any person in any manner OWNER"
so.as to become subject to the Workers' Compensation Laws. Ma1L OCCUPANCY GROUP V- _/ W
ADDRESS ' F��.' 0-
Date—Applicant Date Applicant
TEL z
NOTICE TO APPLICANT: If, after making this Certificate of CITY t ; rvo �' — OCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
• with comply with such provisions or this permit shall be. TRAILER USE.0 ,GEOLOGY;INSPECTIONNO Spec. Knowl. El
revoked.•"
LICENSED CONTRACTORS DECLARATION occurwrvcY INSPECTION Panic Devices El
Ihereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT L 1 (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 REq'D PROVIDED
SPACES
License Number Lic.Class LIMITED TIME USE
ContractorDate' DATE - DATE
_ - - FROM: TO:. -
❑ I am exempt from'the licensing requirements as I am a,
licensed .ai chitect or a registered piofessibnal engineer SIZE OF �\ NO. OF INSPECTOR'S
acting In my professional capacity'(Section 7051, Bus- EXISTING BL U STORIES SI NATURE
iness and Professions Code). FINAL APPROVAL
- PRESENT USE OF BUIL DING �
Lic.or Reg.No. Date I_
HOME OWNER-BUILDER DECLARATION 0.o:OF AND. TING BUILDINGS
ON LOT AND USE
i
I -hereby affirm that- I am exempt from the Contractor's L . 21.1'912,3 A
License Law for the following reason (Section 7031.5, Busi- # o 0'0,0 3 0
ness and Professions'Code): NO.PARKING
SPACES PROVIDED ,
❑ 1, as owner of the property, will do the work and the '805 Q
structure is not'intended or offered for sale (Section
7044, Business and Professions Code).' 'o,o:0.8 Q'5 Q`v
'PROPOSED USE OF BUILDING'.
CONSTRUCTION LENDING AGENCY. o U.Z 5'=85
I hereby affirm that there is a construction lending agency 'f
for the performance of the work,for`,which this-p'ermit is '
issued(Sec. 3097,Civ.C.). f
Lender's Name - PROPOSED MAX'. OCC.
Lender's Address PERMIT Fee /5
I certify that I have read this application and state that theSD
above information is correctagree to comply with all County IssuANCE F
.•[ EE
ordinances and State laws relating to building construction, TOTAL.FEE D
and hereby authorize representatives of this County to enter
upon th Ove-mentioned r .erty for inspection purposes. SEE REVERSE FOR EXPLANATORY,LANGUAGE
nature of Permittee We