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Home My Public Portal About6014 KAUFFMAN AVE_Building__ .WORKERS' COMPENSATION DECLARATION I'hereto s iQsufe bbraafcertdf cate of Worke srlComtpensation eInsuran of APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) y l -/ f COUNTY OF LOS ANGELES ILDING . BUILDING AND SAFETY Policy No. 1% 2 Company �`LQI� r��u� ❑ Certified co is hereby furnished. 5- IS FOR APPLICANT TO FILL IN ADDRESS PY Y �� ` ADDRESS �j Q5 ff V-a- ❑ Certified copy is filed with the county building inspec- BUILDING / //• tion department. ADDRESS (Od ALf�i7i�tA y" I!�' LOCALITY 9 ?/ CITY- � C�t ZIP O Dated - Applicant � NO. OF BLDGS. CERTIFICATE OF EXEMPTION FROM ORKERS' SIZE OF LOT NOW ON LOT NEAREST CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK O� PAGE PARCEL hundred dollars ($100) or less'.) TEL. OWNER NO. USE ZONE MAP I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in any manner ADDRESSV� ,� SPECIAL a CONDITIONS so as to become subject to the Workers' Compensation Laws. � O CITY ZIP (/ V Date Applicant ARCHITECT OR I TEL. DISTRICT GROUP TYPE I FIRE PROCESSED BY 5 NOTICE TO APPLICANT: If, after'making this Certificate of ENGINEER NO. CONST. ZONE Exemption, you should become subject to the Workers V Compensation provisions of the Labor Code, you must forth- ADDRESS � w with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSI�1 A�TIO,N , APT. CONDO. to deemed revoked. CONTRACTOR uh Rin NO Z- ZZ �c='s` '�bVG 5� � Z_ LICENSED CONTRACTORS DECLARATION LIC. / CLASS NO. ELL. U S I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS l0, 6— o No. 6 (commencing with Section 7000)of Division 3 of the Business ,, / I LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY 1`'( 01, I n CLASS C.-- BK.Z---- PG./l �}�d ' 17 VALIDATION rC SQ. FT NO. OF NO. OF CHECK License Number vC6 Lic. Class G��6 SIZE ��1 STORIES FAMILIES ONE ACCT. _• •F $ 2 qL �� yam{ VALUATION ait•C•t°a Contractor Date "✓ �t DESCRIPTION OF WORK /GL c.. NEW LJS b D 01 '14.? El am exempt under Sec; ADD El ALTER 1 1fE4� ALTER ❑ qi B.&P.C. for this reason REPAIR ❑ $ TOTAL 74- 91 Date: USE OF F BLDG. DEMOL ❑ CHECK 74.91Y APPLICANT TEL. Signature ✓ FINAL Q •• i OWNER-BUILDER DECLARATION (PRINT) 61'1 (� `=1" NO �Z13 /Z2 tp DATE 0 ` 3 "� CHANGE ` I hereby affirm that I am exempt from the Contractor's License ADDRESs- Professions S� 3 L, Cam,0117 / [ o+t b� l D Law for the following reason (Section 7031.5, Business and FINAL Pro essions 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 LOCALITY the structure is not intended or offered for sale(Section 7044, Business and Professions Code.) MOVING TEL. ► 4 ITEMS ❑ CONTRACTOR NO. L . - I, as owner of the property, am exclusively contracting �� with licensed contractors to construct the project(Sec-, ADDRESS �' ✓ TOTAL tion 7044, Business and Professions Code.) f.: 1A REQUIRED TOTAL SETBACK FROM EXIST. CHECK 11?.r7=' CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT i: fNi�E ,Iii s the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE. P.L. Lender's Name1 !1a::f'7s•' LDMA Ref. # Lender's Address P.C. Fee Permit Fee tr'.•l6,,�y 1 HNI1=_'I.- I certify that I have read this application and state that the Issuance Fee �� LDMA P/C# 8 above information is correct. I agree to comply with all County Investigation Fee. R ordinances and State laws relating to building construction, Total Fee /� Q LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mentioned roperty for inspection purposes. ^� SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ure of Applican or Agent Da WORKERS' COMPENSATION DECLARATION I hereby affirm that I hwe a certificate of consent to self ®P P L I` ATI®�;� to iV _ �'� I N G PERMIT insure, or certificate of Workers' Compensation Insurance, I� w�/ or a certified copy thereof (Sec. 3800, Lab.' Lamb.' C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Poli No. 00 Company Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING PY Y ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING �p� tion department. ' ADDRESS /-k -7-R J (. (� r 'VI t !Y CITY . ; - ZIP r /�0 LOCALITY Date NEAREST /1 Applicant ` NO. OF BLD 5. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' i SIZE OF LOT t5VIjc�J NOW ON LOT CROSS ST. COMPENSATION INSURANCE, yy ASSESSORD (This section need not be completed if The permit is for one TRACT BLOCK LOT NO. l MAP BOOK �4fPAGE Ge PARCEL hundred dollars ($100)or less.) /� GTEL. MAP OWNER U-1AM USE ZONE NO. /. I-certify that in the performance of the work for which this % NO. -� permit is issued, I shall not employ any person in any manner ADDRESS tF'//P 1�' K'J SPECIAL i 1� f�_ CONDITIONS so as to become subject to the Workers'Compensation Laws. O CITY. � La G-,TT (A ZIP Date Applicant ARCHITECT OR t w TE NOTICE TO APPLICANT: If,.after makingthis Certificate of ENGINEER -w�^/ 14"0)"v N DISTRICT ;GROUP TYPE FIRE PROCESSED BY� CONST. Z NE Exemption, you should become subject to the Workers' U Compensation provisions of the Labor Code, you must forth- ADDRESS 4'f4'�� Y2 �� '� J w N with comply with such provisions or this permit shall be // TEL. 5' STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. CONTRACTOR % ��C� /�L� NO. �3C Z LICENSED CONTRACTORS DECLARATION // LIC. CLASS NO. 6221 DWELL. UNITS L! 1 hereby affirm that I am licensed under provisions of Chapter 9ADDRESS y/ GE's �-' 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. �1 CITY , �. !r ;w , CLASS1�C. BK PG/ f� - VALIDATION SQ. FT. NO. OF NO. OF CHECK O License Number Lic. Clots � `INC SIZE STORIES FAMILIES ONE _ VALUATION Contractor +ate�.r•Q DP_jr��I. Date l �/ DESCRIPTION OF WORK NEW yp 23 ❑I am exempt under Sec. I �DAl�L lj�� ADD ❑ $ ► t_..� s p ALTER d-El' p �2y. G-d'" B.&P.C. for this reason iLC� die $ �Oni '`7 � 1445. USE.OF ,,.I �/ REPAIR"❑ 33C1, 'L' Date: (1) EXISTING BLDG. '5 �G�V"1 I/°L' DEMOL`;'❑ y '.; Signature r Y APPLICANT � TEL. g OWNER-BUILDER DECLARATION \ (PRINT), NO. FINALTOTAL i44,�° , AA I hereby affirm that I am exempt from the Contractor's License �]� 1'ft� �/ p lJ ��_ t ��. ATE j CHECK c U° 9 Law for the following reason (Section 7031.5, Business and 1 ADDRESS t "K '�+c c � l FINAL,• Professions Code): PRESENT By CHANGIE f„; 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 LOCALITYC 7044, Business and Professions Code.) MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. 5248 I AM 7;41 J_ s, with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions.Code.) REQUIRED TOTAL SETBACK FROM. EXIST. e +, CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that There is a construction lending agency for FRONT (� rilC the performance o) the work for which this permit is issued P.L. P/PP!V L � $_j(�, 7 Sec. 3097, Civ. C. . SIDE ; u -, GAJ ” i a. rC J Lender's Name. 3 / iLDMA R,4j.# dh Lender's Address P.C. Fee,$ Permit Fee t J y �+' to I certify that I have read this application and state that the / �7 • r!� Issuance Fee µ � DMA P/C# above information is correct. I agree to comply with all County Investigation Fee �I ordinances and State laws relating to building construction, Total Fee 6�•j .-7. ,� LDMA Perm. # and hereby author ze representatives of this County to enter upo t e above-m io�ed p perry for inspection urposes, r r� r� t••;? "'' �� SEE REVERSE FOR EXPLANATORYJA�UAGE° u" _ ►� ti,, t"7 +"t Signature of Applicant or Agent Date t•. 117-1.1L.J +.., .... t:' i t