HomeMy Public PortalAbout6049 KAUFFMAN AVE_Building__ J WORKERS'COMPENSATION DECLARATION
hereby affirm'that I have 'a certificate-of cansent'to self -APPLICATION FORBUILDING PE
-RM I T'
insure, or a certificate of Workers'Compensation Insurance,
or i r of (Sec. 3800, Lab' C.)
►���iUWntrg COUNTY"OF LOS ANGELES. BUILL)ING-AND-SAFETY,
Policy No. Company Western Employers • -
BUILDING
Certified copy is hereby furnished. FOR.APPLICANT TO-FILL--IN ADDRESS
ry�j Certified copy is filed•with the courity building inspec- BUILDING'
tion department. ADDRESS 6049I KI auffman LOCALITY.�
9/13/85 'Lytle RoofingCo. CITY Temple City ZIP 91780 CROSSST
ST
Date Applicant y •
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS ASSESSOR
COMPENSATION'INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK , : PAGE PARCEL
(This sectiori need not be'completed if'the permit is for one USE ZONE MAP_
. ,
hundred dollars,($100)or less.) TRACT BLOCK LOT NO NO
TEL., SPECIAL
I certif' that in the performance of the work-for which this OWNER Mr. Armin Walther' NO. 289-8891 CONDITIONS IL
y p _ DISTRICT GROUP TYPE FIRE PROCESSED BY, O
permit is issued, I shall not employ any person�in any manner ADDRESS 1 CONST. ZONE V
so as to become subject to the Workers'Compensation Laws. 7j CONS/
1/ ®C'
CITY
ARCHITECT
Date Applicant AOR 4 T ZIP TEL• STATISTICAL CLASSIFICATION.: APT CON 0
NOTICE TO APPLICANT: If, after making'this Certificate-of ENGINEER •%NO. CLASS NO. W
Exemption, you 2 f DWELL UNITS'u should become subject to the Workers' H
Compensation provisions of the-Labor,Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall b,e TEL: Z
,deemed revoked. CONTRACTOR - L tie Roof ing NO. 79275 BK PG. : VALIDATION
LICENSED CONTRACTORS DECLARATION2948• E. Walnut St LIC ' 186303
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION
(commencing with Section 7000)of Division 3 of the Business and Pasadena CA 91 107 LIC 39 r'
Professions Code,-and my.license is in full force grid effect. CITY CLASS poll.
SQ. FT. _ NO.OF NO OF.' CHECK
License Number 186303 Lic.Class C39 SIZE ISTORIES IFAMILIES ONE
DESCRIPTION OF WORK re-roof house." NEW ❑ s
• -Contractor Lytle "Roofing Date 9/13/85" ,. � -92938A
❑ I am exempt under-Sec Fiberglas-sshing4es- R-21- EADD - ❑ — # e c a i aALTER ❑ FINAL OCB.BP.C. for this reason REPAIR ❑ DATE USE OF
EXISTING BLDG residence . DE MOL _❑ By A O 9 1 7_85
Signatur APPLICANT TEL,
OWNER-BUIL R DECLARATION PRINT .Lytle Roofing CO. No. 792-5171.
I hereby affirm that I am a empt from the Contractor's License ADDRESS 2948 E. Wa 1 nut, Pasadena
Law for the following reason-(Section 7031.5, Business and
;-Professions Code): RESENT
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
7044, Business'arid Professions Code). MOVING - TEL
j„as owner of the property, am exclusively contracting CONTRACTOR 'NO
❑ with licensed-contractors to construct the project (Sec-
tion 7044, Business and Professions Code). ADDRESS
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY' SET BACK YARD HWY PROP. LIN 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.L
(Sec. 3097, Civ. C.) SIDE
ro PA
Q Lender's Name
Lender's Address P C. Fee E' Permit Fee 39.38 '
F certify that I have read this application and state that the Issuance Fee 10.50' '
above information is correct. I agree to comply with all County Investigatwn Fee.
ordinances and State laws relating to building construction, Total Fee 49.88
d and her by authorize representat' s of this Count o enter
upon t bove-mentio prop ty for mspect�o urp S.
G��J SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur f Applicant or grn, Date