HomeMy Public PortalAbout5742 KAUFFMAN AVE_Building__ y WORKERS' COMPENSATION DECLARATION
i'�ere,"o as certif carte of Workers' Comtpensation eInsuran of APPLICATION FOR BUILDING PERMIT
i, •certfied copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nard 0'0Su Company 5724 ,I
❑ Certified coy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS• S74-2- VA Ia �.41�7 ,AV,
Certified copy is filed with the county building inspec- FBUILDING ZV` MA AVE--
tion department. RESS 4* T,/1u �,(A L GI's CA, '7' 3V
Date J/I �� Applicant S ��G� Mp� C•+ ZIP CA 7W • LOCALITY `NO. OF BLDGS. CROSS ST. � /� ACERTIF ATE OF EXEMPTION FROM WORKERS' OF LOT 6V X ZOO NOW ON LOT � NEAREST O VG /L!VU- OAK `
COMPENSATION INSURANCE /- ASSESSOR / V m�
(This section need not be completed if the permit is for one TRACT ��� ]BLOCK LOT NO. MAP BOOK PAGE �� PARCEL
hundred dollars ($100) or less.) r• S N' TEL. ,
OWNER µ ��+����S��E NO. USE ZONE MAP jy���
I certify that in the performance of the work for which this NO. �U
permit is issued, I shall not employ any person in any manner ADDRESS fµW I,L(B(O �Q. � -•1' SPECIAL >-
f t �[ c7 CONDITIONS
so as to become subject to the Workers'Compensation Laws. CITY A4 MSI 49 ZIP GH [l i o6 OU
Date Applicant' ARCHITECT OR TEL. q� DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making, this Certificate of SILrOf�M NO 5/0 )?7
ENGINEER CONST. ZONE
Exemption, you should become, subject to.the Workers' 3 U
P v 1 s M V1r= -45 WA u /�
Compensation provisions of the Labor Code, you must forth- ADDRESS �� N•' TR�t �' 14 9-1 4 z 1f / V a
with comply with such provisions or this permit shall be TEL. to
/ STATISTICAL CLASSIFICATION APT. CONDO.
deemed revoked. CONTRACTO 7 L G L(//' -� �• Z
LIC. CLASS NO. DWELL. UNITS
LICENSED CONTRACTORS DECLARATION $
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES9'/U---� %. �✓ L NO. .
}, LIC SEWER MAP
(commencing with Section 7000)of Division 3 of the Business OO,ff✓ G � n--,
CI � W'1A CLASS
and Professions Code,and my license is in full force and effect. gK PG. ''=�' VALIDATION
SQ. FT.;b6 NO. OF -� NO. OF CHECKa 1
License Number Z=-02- Lic. Class SIZE �C�'� STORIES FAMILIES ONE •• t#0.1 °a
VALUATION s s-7 .
Coniracfo Date ( l v DESCRIPTION OF WORK �—OT sl LIT Bu ILT NEW X30 !93"f:S
❑I am exempt un er ec. Arw 2 SpkT S1�((,vc- FAA(,L *tJ5& $r ADD ❑ �~ z , q# ,Tuts
Z-6µk U 7� ALTER ❑ �I I AL 793 c 70
B.BP.G. for This reason REPAIR ❑ $ CHECK Date: USE
EXISTING BLDG. N�• DEMOL ❑ i•HE`�.s•l i 7r�'L"711
Signature APPLICANT �( TEL. FINA / )Q CHANGE CO,
OWNER-BUILDER DECLARATION (PRINT) TiYI 'GIH RTal NO�g .�7504?X DATEL
I hereby affirm that 1 am exempt from the Contractor's License ADDRESS 17� - �VG '4V�'�3 �O��p
Law for the following reason (Section 7031.5, Business and FINAL ELI�O_I7i?f31 / silty.
Professions Code): PRESENT B
❑ I, as owner of the property, or m employees with BUILDING y 6�I96 1 r�l°€10 55
P P Y. YADDRESS
wages as their sole compensation,will do the work and 2
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL. 41,217f7
❑ /j I, as owner of the property, am exclusively contracting CONTRACTOR NO. cy/
with licensed contractors to construct the project (Sec- ADDRESS /
tion 7044, Business and Professions Code.)
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
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.
(Sec. 3097, Civ. C.). SIDE
P.L. -•-C+ t51
Lender's Name.
�� i rye LDIfi1-ARef. #� -.
P.C. Fee$ Permit Fee "" O r--;
Lender's Address .••..I
o i'"1-1
0 1 certify that I have read this application and state that the Issuance Fee r-� LDMFA P/C#
above information is correct. I agree to comply with all County Investigation Fee .
8 ordinances and State laws relating to building construction, Total fee .• LDMA Perm. #
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes. -• t_l [,j C�;i t,••3
O/ 1 SEE REVERSE FOR EXPLANATORY LA .�"UA E "•-, °
�/ Si nature ica or A ent Date f-- t; Lrt '•n t7