HomeMy Public PortalAbout5202 KAUFFMAN AVE_Miscellaneous__ WORKERS" 7sMaaaCOMPENSATIONIDECLARATION 3D,P-W12/9.020-006 _. MISCELLANEOUS APPLCATO®
insure
I ,hereby affirm that...I h the a certificate of-consent to:self COUNTY OE LOS ANGELES BUILDING AND SAFETY DIVISION
or a?certlfof Workers' Compensaiioa Insurance, or.
lcate
a certihed0c60y�hOeof;{Sec:3800, Lab. C:)
Policy No. '`' Company FOR APPLICANT TO FILL IN BUILDING-,
BUILDINGADDADDRESS ... _ _ ._ ADDRESS, #.
_ ,
❑ Certified copy:is?hereby,furnished 11 A17 4
❑ 'Certifiedtcopy is filed"with the county building'inspection cIT t zip-
F71 �•
..-department NEAREST
- i `, - _ CROSS ST.
Date ; AppllCant '� ` SIZE OF L9T - �fVO.OF B'L GS.NOW ON DIST 1 7 GRO _ - TYPE'CONST[�'/J/�,� PRoc 'Bv Y a'
i1 64 x-
j t.•.CERTIFICATE OF EXEMPTION FROM WORKERS'' TRACT -" -'§LOCK "' Lor NO.
.. B'
COMPENSATION INSURANCE.. „ - NO (CIRCLE) STATE MAJOR SECOND
{This seeCI0I1+}Reed alOt-he.'COinpleted if>the WOrk,inVOlVed ASSESSOR MAP BOOK , '- '` PAGE•" PARCEL USE zoNT- SPECIAL CONOITIONs bq the permit is for one hundred dollars ($100) or-_less.)`. �.
fl. :L't•:rt�. �. !..•, e s '•
1. iOW TEL NO.
1 certify that tn,ti,e,:performance of ,the workfor which this I I• '
permit is.'issued'hs)all not employ„any person m ADDRESS any,manner
G9�
so as to become subject to the Workers Coinpen'sation,'Laws.' OCCUPANCY GROUP
Date' a.a APplicarit=, "..' ciTv __ . ZIP e
NOTICE`TO''APPLICANT ;,If, after Ing his Certificate T LOAD
OCCUPAN
of Exemption you,'should.`become.subjecf”to•.the Workers' APPLICATION FOR
Compensatiomprovi"§ions of the'Labor Code,-you must forthwith EXIT HARDWARE:
comply with such iovisions,or.this crmiti-sball-be deemed TRAILER USE
p p p ❑ GEOLOGY INSPECTION❑ NO Spec.Kr10W ❑
revoked.
LICENSED CONTRACTORS DECLARATION -OCCUPANCY INSPECTION - - Panic Devices ❑
I,hereby affirm'that I am licensed under provisions of Chapter _. ._- SAFETY.PERMiT- Z(LIST ITEM BELOW)
9'(commencing with Section 7000)of,Division 3 of,the Business No. xl -
OF EXITS
and-Professions Code.and my'llcense'is to full'for'ce and effect:' hO
. T ae G
Lic..Cass snSRE 'D POVIDED
LicenseNiilnber. ®
Contractor LIMITED TIN509SE
- ,
_.•. DATE , TE
_
❑. I am exempt from the licensing re Qlllrements•as I am a. _ i FROM: 'TO*
-meting
:''licensed
ofesitect oonalregistered professional engineer
SIZE OF - - - - NO.OF INSP TO r
CapaClty.(Section 70511,1 BUSIneSS EXISTING,BLDG. STORIES, S NATURE a 31
and Professions Code):
L1C:'OT.Re NO. ."-; _-` Date '°,' PRESENT USE OF BUILDING _ {..•.' e O
FINAL APPROVAL
{ HOME OWNER,BUILDER DECLARATION No OF EXISTING BUILDINGS �(��}(� (7[�(}t
ON LOT;AND USE .. - _ - _ _ 1.11lt3LF"�Lf001
I hereby affirm that I am exempt from the Contractor's License -, �i10
,"L:aw for the following reason:(Section 7031.5, Business and. � � � ' -
,Profession$."Code)f - y NO.PARKING, 'h .
SPACES.PROVIDED
I, as owner of the,property, will do`the' work and the --
': structure is not intended or offered for sale(Section 7044, PROPOSED USE of BUILDING AC•l•T a
Ir
Business and Professions Code): -
36Q 242.50`
CONSTRUCTION LENDING AGENCY . . _.. .. t
I,hereby affirm that there is a construction lending agency for IT
the performance of the, work for which this permit is issued
'PROPOSED MAXOCC.
•a ._m 0
(Sec: 3097,CIV. C.). TOTAL
Lender's Name APPLICANT PRINT) TEL NO. C`Jp
- i M -HECK /?!
Lender's Address A RES - — _. CHANGE
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County PERMIT FEE , �
ordinances and.State laws relating to building construction,and �'io _ (3(�(�-�(�(� .-5/15/96
hereby authorize representatives of this County to enter upon ISSUANCE FEE
the above-mentioned property r inspection purposes. - - 6452 -4 PM-5 018-
. TOTAL FEE -
?—/r SEE REV 0E FOR EXP ANATORY LANGUAGE
SiSigAnature ofP mittee Date