HomeMy Public PortalAbout5818 KAUFFMAN AVE_Building__ 7 J `NORyERB'COMPENSATION DECLARATION
EBF o cer that I have certificate of consent to Self J APPLICATION FOR' BUILD 1 N G PERMIT c
re,.or a certificate of Workers' Compensation Insurance,
or a certified copy thereof Sec. 3800, Lab. C.)
' d— COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.)) Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING I
ADDRESS
Certified copy is filed with the county building inspec- BUILDING
do denpar ent. ADDRESS v Q
Date 3 T Applicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WOR NO. OF BLDGS. " NEAREST
COMPENSATION INSURANCE SIZE OF LOT (;y NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one / x'114 *" L ASSESSOR
hundred dollars ($100)or less.) TRACT (� ( BLOCK T NO. MAP BOOK .PAGE J7� PARCEL
TEL. �.�/ USE ZONE MAP
I certify that in the performance of the work'for which this OWNER /V NO. 1F6^�Z NO. �S®-,ZCL.
permit is issued, I shall not employ any person in any manner KA SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS / /\ CONDITIONS V
Date Applicant CITY
ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE NiPROC SED BY_..-
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' CONST.• Z E _ W
Compensation provisions of the Labor'Code, you must forth- ADDRESS 'v N
with comply with such provisions or this permit shall be TEL
deemed revoked. CONTRACTOR �gSTATISTICAL CLASSIFICATION APT. DO.
, 1jri[L16� NO. Ob9 "
9-
LICENSED CONTRACTORS DECLARATION ��-. LIQ. •CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS '� L(/, o[7_r17[C - NO. d Zg 2
(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 /4'70&/ 0014 CLASS JL5 BK.Lr//i PG./// VALIDATION
G[!� SQ. FT. NO. OF NO. OF j CHECK
License Number ` V Lic.Class SIZE STORIES / FAMILIES ONE
S / ❑ VALUATION
Contractor �C •✓ ("64 Date .L b DESCRIPTION OF WORK O C��� NEW $ / /
^^ /� ADD [Ll. C./
❑ I am exempt under Sec. � M � � '/ ,
ALTER
B.&P.C. for this reason REPAIR -❑ $
Date:
USE OF ❑
EXISTING BLDG. D[✓t�T/4 DEMOL
4-1
Signature
APPLICANT TEL. '
t- `' FINAL
OWNER-BUILDER DECLARATION PRINT) �^L r?S NO.
�S�I`®I DATE 2 3 g a 1 p -
I hereby affirm that I am exempt from the Contractor's License ADDRESS W i 1 odTlyr ` ��' FINA
Law for the following reason (Section 7031.5, Business and j # o o m o o*1
Professions Code): PRESENT BY
ElI, as owner of the property, or my employees with BUILDING
ADDRESS g I 1 8 1. 1 3..
i
wages as their sole compensation,will do�the work and ® ° a a 1 8 1..1 3 51
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL. O 205; 8 6
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to'construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIREDYARD ' TOTAL SETBACK FROM I T..!
HWY
_ CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH v
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.
Lender's Name
LDMA Ref. #
P.C. Fee$ - Permit Fee a
Lender's Address kLD
I certify that I have read this application and state that the Issuance Fee P/C#
Q above information is correct. I agree to comply with all County Investigation Fee
0 ordinances•and State laws relating to building construction, Total Fee 13 LDMA Perm.•# - '
v and hereby authorize representatives of this County to enter
up th above-mentio d property for inspection purpo es.
dSEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or 4t- D to - - -
- C•
APPLICAZTON,'.;FOR' PERNW
•AND.:•SAFETY��, •.. - -. Lv� ANGELES-' ING *,
F NBER BUIL
OX CHI E! [NGI
•
• ' �''.:1.:.t;''.'•
f,
xty
5
No. OF ' BLDG. ORD. NO. DISTRICT'NO.' TLAN CK. NO. PBRMf! NO.-
PLANS SETBACK
FIRE 'A PROVED IN
ZOI'= tSY RECEIVED By_ OATIK OF-APDL. DATI fl wa=
USEAPPROVEO ok
v vW'�• 4o
`�
ZON BY ,v
C FILL IN HEAVILY' OUTLINED PORTION: .0 ONLY ^°
BUILDING r,y
E NAME ADDRESS is
W
lit Z ADORES LOCALITY rs
xZ NEAREST %'yr
0 Z `CITY CROSS ST. :tet
< STATE
'TEL. , , ^t7 =� +Li✓t�• /L.... �;M
LICENSE NO. NO. Ty� NAME k.Y s
O, NA. r MAIL:
ADDRESS �'•'="?!
'h
/4^ / TEL.
< ADDRES / GITY NO.
Z CITY t HEREBY ACKNO EDGE THAT i HAVE'READ THIS,-
O APPLICATION AND'BTATS THAT THE ABOV2.Is G GT.. ;,..
U STATE TEL. AND AGREE TO COMPLY WITH ALL COUNTY;ORDIi#*ZOCSS
LICENSE NO. NO. AND STATE LAWS REGULATING BUILDING CONSTRt L-nat.:
LOT. NO. .� 9 SIZE OF LOT v O•X SIGNATURE OF }'.�
_ -- OWNER
NO. OF BLOCS. AUTHORIZED ACT. ;irs;k
o BLOCK.' . NOW ON LOT q
m TRACT G S!d CORRE IONS `k
5•.
O USE OF SLOGS.
NOW ON LOT
DESCRIPTION OF., WORK �
J.
'f _ Z'
e, NEW TYPE OROUPl�d•.'
�. ... _ NO: OF... NO. OR L h:
ALTERATION• ROOMS FAMILIES
/ '` -',•,
ADDITION
y REPAIR' STORIES
t I.1o�V'ING WALL'COVRRIN �+•:"" rt.:e: "Jf, _ :rrt
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