HomeMy Public PortalAbout5946 KAUFFMAN AVE_Building__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self ' PERMIT
nsure, or a certificate of Workers' Compensation Insurance, *PLICATION Fu
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING 1" r
ElCertifiedcopy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 0 J=-F�1-A ,ST
❑ Certified copy is filed with the county building inspec- BUILDING
IU I ( `7T V Tom!V
tion department. ADDRESS –I, / J�
Date Applicant CITY LL tT & eIP C. [7 LOCALITY �� CI
NO. OF BLDGS. NEAREST I
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT (J NO O LOT CROSS ST. (,. 5 -RIAht
COMPENSATION INSURANCE OVIASSESSOR 7
(This section need not be completed if the permit is for one TRACT LOT NO. IDS MAP BOOK / Z PAGE 3 PARCEL �G
11
hundred dollars ($100) or less,) USE ZONE MAP
OWNER � NO.
I certify that in the performance of--the work for whicK.1his NO.
permit is issued, I shall not employ any pgrson t rte/ anner / ADDRESS ? > ' SPECIAL a
-&In / CONDITIONS
so as to become subject to the Workers', p nws. O
CITY <1^ !ll ZIP
Date ��L �LfCIL
Applic�t ARCHITECT R `� E
NOTICE TO APPLICANT:–If;;after `ok this Certificate,-of ENGINEER �tv J U f C i DISTRICT GROUP TYPE FIRE PROCESSED BY
CONST. ZONE F-
Exemption, you should be;ome�subject�to--the_Workers' 2 U
Compensation provisions of the-{obor Code, you must forth- ADDRESS / i. N a
with comply with such provisions or this. permit shall be 1 f TEL / 5 7 S ATI ICAL CLASSIFICATION APT. CONDO. v7
deemed revoked. CONTRACTOR LYtic S+4 L L–L_ NO�I f[, �7/ Z
LICENSED CONTRACTORS DECLARATION 1 G t LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS % NO.
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY Ci(�L �j�'i - CLASS BK VALIDATION
SQ. FT. � NO. OF NO. OF CHECK
License Number Lic. Class SIZE 2 f STORIES Z FAMILIES ONE
VALUATION S� # 9 0•
DESCRIPTION OF WORK (� NEW I�
Contractor Date ti ADDY_] $ Oft-� r— * Z
❑I am exempt under Sec. r-' /�J w�� r
� / T ALTER ❑ a * IVL838. i.
B.&P.C. for this reason CSG --7 REPAIR ❑
Date: USE OF
EXISTING BLDG. DEMOL ❑
04. =01.- 91
Signature APPLICANT .� E•
OWNER-BUILDER DECLARATION (PRINT)AL ' f& ,�� FINAL
�j �i 'J DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS -C Jfi�
Law for the following reason (Section 7031.5, Business and FINAL
Professions Code): PRESENT By
BUILDING
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY n
7044, Business and Professions Code.) MOVING TEL. 7
❑ 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.) u
REQUIRED YARTOTAL SETBACK FROM EXIST. * 1 –
8 1 8. 2
D HWY
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.1. 0 4. .– 0 1. – 9 1
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name.
r•�
LDMA Ref. #
Lender's Address P.C. Fee$Iv t✓' P rmit Fee
I certify that I have read this application and state that the Issuance Fee LDMA P/C#`
above information is correct. I agree to comply with all County Investigation Fee
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.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote