HomeMy Public PortalAbout5728 KAUFFMAN AVE_Miscellaneous__ NaJRKERS'COMPENSATION DECLARATION CE 8754(2-80) MISCELLANEOUS APPLICATION
I affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insu a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab. C.)
Policy No. ADD
Company FOR APPLICANT TO FILL IN RBUILDNESS
ADD RE
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❑ Certified copy is hereby furnished. BUILDING �r•� `m
ADDRESS wJ /V' LOCALITY
Certified copy is filed with the county building inspection —� /.� NEAREST
department. LOCALITY %l /' � CROSS ST.
Date Applicant NEAREST a/v, (C ill DISTRICT NO. G OUP TYPE PRO S ED BY
CROSS ST. /V� -/f(( - CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL .
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAV HIGHWAY STATE MAJOR SECO D LOCAL
NO. (CIRCLE) O
(This section need not be completed if the work involved NO. of LOT
l p TRACT NOW ON LOT U.SE ZONE SPECIAL CONDITIONS � V
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT _ EXISTING BLDG.
I certify that in the performance of the work for which this t 0'
permit is issued, I shall not employ any person in any mannerOWNER
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so as to become subject to the Workers' Compensation Laws. A JY � OCCUPANCY GROUP R-� d
MAIL'
' ADDRESS N
Date Applicant
NOTICE TO-APPLICANT: If, after making this Certificate of CIT L/�f}j�"� f N0. OCCUPANT LOAD
Exemption, you should become subject do the WorkersAPPLICATION 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. Know(. ❑
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS
9 (commencing with.Section 7000) of Division 3 of the Busi- ti
ness and Professions Code, and my license is in full force and y�' PARKING
effect. / `LY 4V 41 d IV a SPACES RI- PROVIDED
J �J
License Number Lic.Classy LD
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 (NSP croR's'
acting in ,my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES 7F92
SI ATURE
iness and Professions Code). - PRESENT USE OF BUILDING _ FINAL APPROVAL
Lic.or Reg.No. Date (( LLNO.OF EXISTIN BUILDINGS 6,V A
HOME OWNER-BUILDER DECLARATION ON LOT AND USE
I hereby affirm that- I am exempt from the Contractor's
# • • • •.30
License Law for the following reason (Section 7031.5, Busi-
.ness and Professions Code): No. PARKING j I o 0 8050
SPACES PROVIDED
❑ I, as owner of the property, will do the work and the •.e 0,8 5 0 U
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
PROPOSED USE OF BUILDING 07,30-85
CONSTRUCTION LENDING AGENCY
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 O
- PERMIT FEE
I certify that I have read this application and state that the PO
above information is correct.I agree to comply with all County ISSUANCE FEE _
o 'Dances and State laws relating to building construction, TOTAL FEE /./� f
and hereby authorize representatives of this County to enter 0(/a
above-m/e Toned property for ins ection purposes. SEE REVERSE FOR.EXPLANATORY LANGUAGE V1
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Signature of Pmittee De
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