HomeMy Public PortalAbout4938 KAUFFMAN AVE_Building__ WORKERS'COMPENSATION DECLARATION
a certificate of
insure,ora6 certificate of Wconsent
Workers'Compensation Insurance,
or a certified copy thereof (Sec. 3800, lab. C.)
,. COUNTY OF LOS ANGELES _. .� BUILDING AND SAFETY
Policy N .V83-22515kompony Fremont Indemnity
BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
® Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS 4938 N. Kauffman/ -LOCALITY _
NEAREST .
Date II IR193 'Applicant Virgin Rnnf 'Cna CITY Temple City ZIP CROSS ST.
.CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. !ASSESSOR/
COMPENSATION'INSURANCE SIZE OF LOT NOW ON LOT MAP B PAGE PARCEL
(This section need not be completed.if the permit is for one USE ZONE MAP "
TRACT BLOCK LOT NO.
hundred dollars'($100)or less._) J NO.
- - - TEL. �/ SPECIAL �
I certify that in the performance of the work for.which this OWNERMrs. Bray NO. CONDITIONS
ermit.is issued, I shall not employ an person in an manner DISTRICT GROUP. TYPE FIRE PRO SSED BY V
p P Y Y P Y 'efICONST. ZONE
so as to•become subject to the Workers'Compensation Laws. ADDRESS` 9Kauffman
Date Applicant CITY• Temple 'CityZIP STATISTICAL ASSIFICATION APT.. COND u
NOTICE TO APPLICANT: If, after making this'Certificate-of ARCHITECT OR TEL.
. ENGINEER NO. CLASS NO. DWELL. UNITS LU'Exemption, you should become' subject to the Workers' H
Compensation provisions of.the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall.be y
deemed revoked. TEC. BIC PG VALIDATION
CONTRACTOR V i t i Roof. NO. . 87-0 0 .. "r
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9. ADDRESS, .P O BOX J NO. 160650 VALUATION '
(commencing with Section 7000)of Division 3 of the Business and LIC..
Prof essions•Code, and my.license is in full force and effect. CITY Sari Gabriel 91778 CLASS C39 $1719.00 D
SQ. FT: NO. OF NO. OF CHECK
License Number 160650 Lic.Class C39 SIZE STORIES IFAMILIES ONE
$
Contractor Virgh/8183in Roof CO. Date. �8I83 DESCRIPTION OF WORK Re-roof house. & NEW Q
ADD. 0
I am exempt under Sec. garage with 220P Class A
ALTER `FINAL �+� r
B.BP.C. for this reason ^N a DATE G �'
USE OF - FINAL -
Date:. EXISTING BLDG. DEMOL By
APPLICANT TEL.
Signature OWNER-BUILDER DECLARATION PRINT Virgin Roof .•Ca. NO.287=0507 6 8.9.2 A
I.hereb affirm that I am exempt from the Contractor's License
y P O Box J San..Gabriel 91.778. ,# ° 1
Law for the following reason (Section 7031.5, Business and ADDRESS. P. . ,
Professions Code): PRE ENT 2 ° ° 4'9,818
Q I, .as owner of the -property, BUILDING
or my employees with ADDRESS '"~ o 0 0 (j q =
8
wages as their sole compensation,will do the work and� '
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL. t1 7783
1, 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. SET BACK 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 P.L.
(Sec. 3097, Civ. C.). SIDE
m 'P:L. - --
a Lender's Name
Lender's Address - P:C.Fee$ Permit Fee $39.38 -
I certify that'l have'read this application and state that the Issuance Fee 10.50 -
above information is correct. I agree to comply,with,all County Investigation Fee
g ordinances and State laws relating to building construction, Total Fee 49.88
u and heipeloy authorize representatives of this County to enter
m upon t e above-mentioned pro erty finr inspection purposes.
a - S
� SEE REVERSE FOR EXPLANATORY-LANGUAGE.
I Si lure of App icant or Agent Date ®s
i