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Home My Public Portal About5710 KAUFFMAN AVE_Building__ WORKERS'-COMPENSATION DECLARATION ent to sf insure, orairm afcertif catte of Worke s'TComtpensat oof n Insurance,, APPLICATION. FOR BUILDING PERMIT 1LIt or a certified copy=ihereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING 7 tion department. ADDRESS ) LOCALITY / NEAREST Date Applicant CITY ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' gam' /�j�^d .OF BLD S. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT _/4O 0 OW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE NE MAP hundred dollars ($100)or less.)' TRACT BLOCK LOT NO. ' NO. TEL.�f y� SPECIAL } I certify that in the performance of The work for which this OWNER N0. � (J CONDITIONS CL permit is issued; I shall not employ an pep rrtn an manner ,r- DISTRICT GROUP TYPE FIRE TBY O P P Y Y P Y r Q� CONST. ZONE IM so as to become subject to the Worker Compens ti3n L s. ADDRESS-, 06 J `� Applicant CITY ZIP , O Dare- ARCHITECT OR EL. STATISTICAL CLASSIFICATION APT. JCJDO. V NOTICE TO APPLI ANT: If, after making t s Certificate of ENGINEER NQ. CLASS -7 NOTICE UNITS LU Exemption, you should become subject o the Workers' CL Compensation provisions of.The Labor Cod you must forth- ADDRESS SEWER MAP rA with comply with such 'provisions or this permit shall be deemed revoked. TEL. CONTRACTOR NO. BK PG VALIDATION LICENSED CONTRACTORS DECLARATION' LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 o $ fJ f The Business and LIC. �� J L� Professions Code, and my license is in full force and effect. CITY CLASS r SQ. FT. NO. OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE Contractor Date DESCRIPTION OF WORK NEW $ �{ I( ADD 1 am exempt under Sec. !O ALTER, FINAL B.&P.C. for this reasonC DATE REPAIR Date: USE OI F BLDG DEMOL E] FIN EXISTBY Signature APPLICANT TEL WAVC OWNER-BUILDER DECLARATION *, PRINTZIA NO. I hereby affirm that I am exempt from The Contractor's License Noll.Law for the following reason (Section 7031.5, Business and ADDRESS . Professions Code): PRESENT ;2 6 39,3 A BUILDING I Lit I, as owner of the property, or my employees with ADDRESS # 0 0 0 0 0,1- wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY o o (J.9, 8$ 7044, Business and Professions Code).' MOVING TEL, o 0 0 9 8= I, as owner of the property, am exclusively contracting CONTRACTOR NO. 0 1.2 6 U a 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 ' 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 P.L. e Lender's Name Lender's Address P.C..,Fee$ Permit Fee t I certify that I have read this application'ond state that the Issuance Fee CJ M above information is correct. I agree.to comply with.all County Investigation Fee g ordinances an tate laws relating to building construction, Total Fee u and her authorize representatives of'this County to enter 9 upo t e above-me ned roperty for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE n / Signatu of Applicant or Agent Date r ®5 WORKE;RS'COMPENSATION'DECLARATION i p net by of that I haver certificate of consent to self APPLICATION FOR BUILDING P E RM I T IL insure, or. certificate of Workers' Compensation Insurance, or.'certified copy thereof (Sec. 3800, Lab. C.) COUNTY:OF LOS ANGELES BUILDING AND SAFETY Policy,No._, . Company BUILDING F] Certifiedcopy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS l{¢ /�IA/1� ❑ Certified copy is filed with the county building inspec- BUILDING i tion department. ADDRESS //�� Date Applicant CITY ZIP LOCALITY G lam/ CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST _/I /)r1 COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT S CROSS ST. . L-I VE UIQ" (This'section need not be completed if the-permit is for oneASSESSOR hundred dollars ($100)or less.) TRACT J r BLOCK / LOT NO. /'� [ MAP BOOK PAGE PARCEL NO J �7 USE ONE MAP OWNER ( ' I certify that in the performance of the work'for which this NO. - } permit is issued, I shall not employ any person in any manner - SPECIAL - d so as to become subject to the Worker 'C p sation Laws. ADDRESS CONDITIONS O (, , CITY ZIP V Date Applicant �l NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR ` � NO. �S S-�1 DISTRICT GROUP TYPE FIRE. _ PROCESSED .. ENGINEER l9 r CONST] ZONE LU Exemption, you should become subject to the Workers' / `j ® V 3 W Compensation provisions•of the Labor Code, you must forth- ADDRESS , L- } /� with comply with such provisions or this permit shall be TEL. r STATISTICAL CLASSIFICATION APT. C NDO: Z deemed revoked... CONTRACTOR fiJf ac 15 NO� b /T LICENSED CONTRACTORS DECLARATION _ LIC• ,, ; r CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O NO.J (commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY \ CLASS BK VALIDATION SQ. FT./$�� NO. OF NO. OF CHECK License Number 'Lic.Class' SIZE STORIES FAMILIES ONE 4• j 6ftR G� O° s.f=. VALUATION "r DESCR OFF ION W RK - NEW � �y��, Contractor Date ❑ $ t�DV ❑ I am exempt under Sec. - \ �� ADD ALTER ❑ , 3 O 7�i �} B.BP.C. for this reason REPAIR ❑ $ 1 O 6 5or' 0, ` Date:" USE OF DEMOL ❑ p 1 ar x EXISTING BLDG. I p z J APPLICANT, ' TEL Signature FINAL j�, OWNER-BUILDER.DECLARATION PRINT NO. DATE (f�d I hereby affirm that I am exempt from the Contractor's License ^ Law for the following reason (Section 7031.5, Business and ADDRESS FINA Professions Code): PRESENT By ! ❑ BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended.or offered for sale(Section LOCALITY 2 41 2-1 "A''• 044, Business and Professions Code). MOVING TEL. " as owner of The property, am exclusively contracting CONTRACTOR NO. # 0 0 0 0 0 1 with licensed contractors to construct the project (Sec- ADDRESS • 775, 50 tion 7044, Business and Professions Code). 0 — REQUIRED. TOTAL SETBACK FROMEXIST. - CONSTRUCTION-LENDING AGENCY SET BACK YARD HWY PROP:LINE WIDTH o 0 775.500"-: 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. Q 2.2 6 8 6 (Sec. 3097, Civ. C.). SIDE -- , P.L. - Lender's Name o LDMA Ref. # - - - -- - P.C. Fee$ 6620.2,5_-- Permit Fee 6 r VV Lender's Address > ,� /l .1 certify that I have read this application and state that the - Issuance Fee r'J Sv •, kLD P/C# n above information is correct. I agree to comply with all County Investigation Fee ^ - o ordinances and State laws relating to building construction, _ Total Fee / LDMA Perm. # ti and hereby authorize representatives of this County to enter u ove- t' ed property or inspection purposes. r � - d SEE REVERSE FOR EXPLANATORY LANGUAGE Signature�, �of Applicant or Agent Date '- -