HomeMy Public PortalAbout5719 KAUFFMAN AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CES75 (11-84) MISCELLANEOUS APPLICATION
- CE 875
I hereby affirm-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. CompanyFOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. BUILDING %
ADDRESS LOCALITY
,
Certified:copy is filed with the county building inspection LOCALITY Q 0 NEAR EST
department. - 1 PL E Ci Y � TY cRoss sT.
Date Applicant NEAREST �� DISTRICT O. G U TYPE PRO ED BY .
CROSS ST. QAK, !/ / CONST..
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (� \ v V
COMPENSATION INSURANCE DESCRIPTION LOT No. J BLOCK , MAP HIGHWAY
_ NO. (CIRCLE) STATE MAJOR SECOND L CAL
/ NO. OF BLDGS. _
(This section need not be completed if the work involved TRACT G S V' NOW ON LOT IUS§ 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 Lor SJ Q EXISTING BLDG. O
permit is issued,'I "shall not employ any person in any manner OWNER B�P„(4'`�/iL( aL►� K' `'
so as•to become subject to,the Workers' Compensation Laws. MAIL M OCCUPANCY GROUP �� o
ADDRESS
Date ,Applicant
NOTICE TO'APPLICANT: If, after making this Certificate of -CITY' -('_ TN.. '2;J? — 3 3/y OCCUPANT LOAD
Exemption, -you should become subject tothe, Workers' APPLICATION FOR EXIT HARDWARE.
Compensation provisions of the Labor Code,you must forth
With comply with such provisions or this permits shall be TRAILER USE ❑ , GEOLOGY INSPECTION El No Spec. Knowl.
deemed revoked. Panic Devices
LICENSED,CONTRACTORS DECLARATION OCCUPANCY INSPECTION [
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 , y / A
_ QG /
/^6 'REQ'D PROVIDEDeffect. �•
SPACES JJ
License Number Lie. Class
' LIMITED TIME USE
Contractor Date DATE DATE
ElI am exempt from the licensing requirements as I am a FROM. TD.•
licensed architect or a registered professional engineer SIZE OF NO. OF INSPEcC 0R'S
acting.in my professional capacity (Section 7051;Bus EXISTING BLDG. 2 O X ZO STOR1Es TURE
iness and Professions.Code). I FINAL•APPROVAL
PRESENT USE OF BUILDING / XVjG�A
•i/�
Lie.or Reg.No. Date
6 1 ,3,0 A
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE # O O O 9130
I hereby affirm that I am exempt from the Contractor's, '
License Law for the following reason (Section 7031.5, Busi- ) e • 8.Q 5 0
ness and Professions Code): -• NO. PARKING
" -
I, as owner of-the property, will do the work and the SPACES PROVIDED o 0 0 8 a'5,0.6,
structure is not intended or offered for sale (Section
7044,Business and Professions Code). 'I 2,1 8 8 6
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
I hereby affirm .that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
' '
I certify that I have read this application and state that the PERMIT 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 pf this County to enter TOTAL FEE Q -
upo e b ve-ment' ned pr rty r inspection purpo es.
f SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature Of Permittee D to