HomeMy Public PortalAbout5746 KAUFFMAN AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444
CE 875 (11-84) M ISCELLANEOUS APPLICATION {�
I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION LJ
insure, or a certificate of Workers'Compensation Insurance,
e,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No.-Company FOR APPLICANT TO FILL IN BUILDING `Nt 4oijem� �&
ADDRESS J 'Ili /'7
Certified copy is hereby furnished. BUILDINGr7,/(p A uo:W,+rJ Ave LOCALITY "r��/�QLE' C'�
ADDRESS J T /�
department.t py is filed with the county building inspection LOCALITY ��e�� / / -�� NEAREST 1 l 1 D �MA S JQ
r ` \ CROSS ST. W •,1 rr
Date Applicant NEAREST \0�� � J DISTRICT NO. UP TYPE PROCES ED BY
CROSS ST. w /� CONS
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL {1)
COMPENSA'T'ION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY
H0. (CIRCLE) STATE MAJOR SE CO OCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT 41 04 1 NOW ON LOT use: ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE of 5 I.'
SIZE OF LOT x ��0- EXISTING BLDGf �w�t,• I 1
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner. OWNER TA MIS PA V l Ds
so as to ecome subject to the orkers' Compe on Laws ` 'OCCUPANCY GROUP o
MAIL
ADDRESS .1�'. .1 '� U
Date �' Applicant 1 LLI
NOTICE O APPLICANT: Iqte
ter making this,Certificate of CITY NOL OCCUPANT LOAD
Exemption, you should be subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions ofLabor Code, you must forth-
with comply with such provisions "or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
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 L/V/luL1�OIK FM
effect. /VS 6- PARKINGREq'D PROVIDED
License Number Lic. Class t CHEN • _L G wt "Roo4K
SPACES LIMITED TIME USE
Contractor Date DATE DATE
El I'am exempt from the licensing requirements as I am a
PROM• TO:
licensed architect or a registered professional engineer SIZE OF FA NO. OF / INS PE TOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. 35'� ! T sT-R.E. SIG ATURE
iness and Professions Code). FINAL APPROVAL
.�
Lic.or Reg.No. Date PRESENT USE OF BUILDING ,
01
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's 202 S 3,
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING #:• •••:!�
I, as owner of the property, will do the work and the SPACES PROVIDED
structure is not intended of offered for sale (Section � � •� I't•"°"
r ;
7044,Business and Professions Code).
���� •�\• e e cJ
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING_ 5
V
I hereby affirm that there is a construction lending agency �� 4 ;,�;-�.�'2.1 '`;8$'
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name \ 202514� A
- PROPOSED MAX. OCC. � ,
Lender's Address
PERMIT FEE - �a #•O'O O;e 3 O
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FEE I '-,*'8 0,5 0
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE - _
upon the above-m n ned property for inspecti n pu oses. s•o e 8 0.5
p,�
,7 � � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee bate