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HomeMy Public PortalAbout6036 KAUFFMAN AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 CE 875 (2-80) MISCELLANEOUS APPLICATION I herq-by affAn that I have a certificate of consent to self COUNTY OF:LOS ANGELES BUILDING AND SAFETY DIVISION�— insure, ora certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab. C.) Policy No. Company FOR 'APPLICANT TO FILLJN BUILDESSING O� ❑ ADDR _ Certified copy is'hereby furnished. BUILDING Tem le Cit LOCALITY.., LOCALIT .. • 6'036 ADDRESS 'Kauffman P. Y>' Certified copy is filed with the county building inspection ' ' '•1 NEAREST department. LOCALITY CROSS ST. Date Applicant - NEAREST t . DISTRICT NO. GROUP TYPE / PR ESSED,BY CROSS ST. Garibaldi r3 CONS T.� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE. DESCRIPTION LOT NO. 109• BLOCK MAP HIGHWAv •1 STATE MAJOR SECOND LOCAL "d .. NO. (CIRCLE) NO. OF BLDGS.' 0 (This section need not be completed if the work involved TRACT 6561 NOW ON LOT 1 USE ZONE �7�,:CIAL CONDITIONS U by the permit,is for one hundred dollars ($100) or less.) _ /////J •t. USE T F ' JJ �7y SIZE OF LOT 6O XZOO EXISTING BLDG '�`I certify thatin the performance of the work Cr for which this0 permit is issued, I shall not employ any 'person in any-manner OWNER Jose R Cortez U so as to become subject.to'the Workers' Compensation'Laws• MAIL OCCUPANCY GROUP j�, 3 W ADDRESSg724 East Garve Ave. - ` �l a Date ApplicantZ 'TEL. NOTICE TO APPLICANT: If, after making this Certificate of CITYRosdmead',- Ca.' NO. 81-8"280-2300 OCCUPANT LOAD Exemption, you, should become-subject to the- Workers' APPLICATION-FOR. EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth-. ' with.'comply with such provisions or this permit shall be , ' TRAILER USE❑. GEOLOGY,INSPECTION NO Spec. Knowl. ❑ deemed revoked. ❑ 1, OCCUPANCY INSPECTION t Pani: Devi6es •iI LICENSED'CONTRACTORS DECLARATION' ❑ I hereby affirm that I am'licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of-the Busi- ness and Professions Code,.and my license is in-full force and Final IYnspeetion" �l/�/ate PARKING effect. REO'D• D PROVIDED D �—• SPACES License Number Lia Class �71.J© d OrJ I'd'o5o5 LIMITED TIME USE. Contractor Date �a S� �4 USa DATE_ DATE ,❑ 6.'•N• FRO M' P TO: I am exempt from the licensing requirements as I am a, licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus XISTING',B LD G. STORIES SIG iness and-Professions Code). PRESENT USE OF Bu1�DING' FINAL APPROVAL Lic.or Reg.No. Date 1:�/ ` • Residence �•C•, .g NO.OF EXISTING BUILDINGS' ?(I HOME OWNER-BUILDER-DECLARATION _ ON LOT AND USE I hereby affirm that, I am' exempt. from the-Contractor's i; ITE,i • License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING _ 1 {AL 93- 00 - SPACES 3- 00 -SPACES PROVIDED I, as owner of the property, will do the''work and the `?3e1i?i • structure is not intended or offered for sale (Section '7044, Business and Professions Code). tt itil3t ,j i? PROPOSED'USE;OF BUILDING , CONSTRUCTION LENDING AGENCY I hereby affirm that •there is a construction lending agency, i 1=iit_sii3 .• #i ,i.• j for the performance of the work for which this permit is issued Sec. 3097,Civ.C. . Lender's Name PROPOSED MAX. OCC. Lender's Address - PERMIT FEE C,(J••� 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 4.49 ordinances and State laws relating to building construction, TOTAL FEE �0 'and hereby authorize representatives.of this Co my to rater upon the above- tion pro y for inspec on pur oses. SEE REVERSE FOR PLANATORY LANGUAGE Si nature of Permittee Dat