HomeMy Public PortalAbout5115 KAUFFMAN AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
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CE 875 (11-84) MISCELLANEOUS
nSCELLANEO S A P P L�C AT I O
IN
I hereby a cera•that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No.-Company
FOR APPLICANT TO FILL IN BUILDING ��
ADDRESS
FICertified copy is hereby furnished. BUILDING�r Yc4 LOCALITY
ADDRESS N'` UX
Certified copy is filed with the county building inspection LOCALITY 2F NgAREs r
department: CROSS ST.
Date Applicant NEAREST DISTRICTN GRQQQ��IUP TYPE PROC SED BY
CROSS GA ,�0 ��� CONST, / -
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL C (J
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK?` MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SE CON OCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred-dollars ($100) or. less.) USE OF
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. O
permit is issued, I shall not employ any person in any manner OWNER y 04* _-D
so as to become subject to the Workers' Compensation Laws. MAIL ¢� a( OCCUPANCY GROUP a
E`
ADDRSS;5sd�3/+
dJ ,� C3
Date Applicant
TEL? OCCUPANT LOAD °-
NOTICE TO APPLICANT: If, after making this Certificate of CITYAj:rEwAfi ` No. Ig c
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 ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION [ � 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. jE1VCLq_Zp qa cdPARKING
SPACES REO'D PROVIDED
License Number Lie. Class J
LIMITED TIME USE
Contractor Date &A / 'DATE DATE
FROM: TO:
_ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF IN/.G-AT-R!
PECTOR•S
EXISTING BLDG. STORIES
acting in my professional capacity (Section 7051, Bus- �
iness and Professions Code). it PRESENT USE OF BUILDING t FINAL APPROVAL
�Nc
Lie.or Reg,No. Date /
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS 0
ON LOT AND USE E pIJ
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- 0 7 9,8 A
ness and Professions Code): NO. PARKING
❑ I, as owner of the property, will do the work and the SPACES PROVIDED }{ °r° 0,0..30
structure is not intended or offered for sale (Section }1
70.44,Business and Professions Code). 1 ° ° 8 Q 5;0
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
8a5.05
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is ti o 9.2 8;=8 8
issued(Sec. 3097,Civ.Q.
Lender's Name
h
PROPOSED MAX. OCC.
Lender's Address
I certify that I have read this application and state that the PER FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of. this County to enter TOTAL FEEJA
upon the above-men •oned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date