HomeMy Public PortalAbout6003 KAUFFMAN AVE_Miscellaneous__ WORKERS:COPaPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION
• ,"�I � CE 875 (11-84)
I hereby a cert that I have a certificate of consent to c self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'.Compensation Insurance,or-
a certified copy thereof,(Sec. 3800,Lab.Q. r•�
Policy No. Company I FOR APPLICANT TO FI LL IN BUILDING A ,
ADDRESS-
FICertified copy is hereby furnished. Bu1LDING S V LOCALITY
_ ADDRESS �1 ' '
❑ Certified copy is filed with the county building inspection i
LOCALITY (� NEAREST
department. �vv� 1e_ CROSS ST.
Date Applicant NEAREST 1 /QD �u DISTRIC NQQQ/ GROUP �TYP§( PROCES D BY
CROSS ST. VV �(/ - 2 CON T -
CERTIFICATE OF EXEMPTION FROM WORKERS'
LEGAL
COMPENSATION INSURANCE DESCRIPTION- LOT NO. " .7 BLOCK MAP HIG XW AY
_ NO. (CIRCLE) STATE MAJOR SECON LOCAL
NO. OF SLOGS.
u
(This section need not be completed if the work involved TRACT 1 NOW ON LOT US ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) I`� tJ
SIZE OF LOT I Vx .� ♦/ EXISTINGsEofBLDG, i�eSl�ZV< _�
L d
•I•certify that in the performance of the work for which this o
permit is issued, I sliall not employ any person in any manner OWNER }�CI�'
so as to become subject to the-Workers' Compensation Laws. J OCCUPANCY,GROUP�',� '
MAIL Z 1/j/ ` �•�I I 4� ♦ \ Lt • 1 `• `` �'\-, O
ADDRESS 0 C) " \//l/"b l V�CI �4 'C. �.�, y •.`
Date Applicant l •� \•-,..- ,,,
NOTICE TO APPLICANT: If, after making this Certificate of CITYT� �1e �+Jt No� D �jS-y(?31 OCCUPANT LOAD
Exemption;•-you- should•-become- subject to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth- ❑
Wdeemed revoked.ith comply with such provisions or this permit shall be TRAILER USE E] No INSPECTION ❑ No Spec. Know].
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. OFEXITS
ness and Professions Code,and my license is in full force and
effect. �N� SPACES REq D PROVIDED
License Number Lic. Class ` /,-3 LIMITED TIME USE
Contractor Date DATE DATE
DI am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional engineer SIZE OF NO. OF INSPE CTOR•S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING .�
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE + #'O O,0•O 3 O
I hereby affirm that I am exempt from the Contractor's I • • $Q 5 0
License Law for the following•reason (Section 7031.5,-Busi=
ness and Professions Code): NO, PARKING _
SPACES PROVIDED \+ R� 5
El
I, as owner of the property, will do the work and the `�� o a•�o v Q ,Q L'
structure is not intended or offered for sale (Section
7044,Business and Professions Code). 12 _8 8
PROPOSED USE OF BUILDING ` ��'��`�'• t � I d�bJ R_ J •`jJ,i�• ,'� y -y .�"
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
i
PROPOSED MAX. OCC. ._
Lender's Address ^ - • -
t V
I certify that I have read this application and state that the PERMIT FEE '
above information is correct.I agree to comply With all County ISSUANCE FEE /030
ordinances and State laws relating to building construction, - % O
r.
and hereby authorize representatives of this County to enter TOTAL FEE S
UP n the above-ment• re or inspection purpos7S. '
SEE REVERSE FOR EXPLANATORY LANGUAGE
5--12-8
Si ture of Permittee Date