HomeMy Public PortalAbout6114 KAUFFMAN AVE_Miscellaneous__ •WORKERS'.CCIIMPENSATION DECLARATION 76M444 "
CE875 (2.80), MISCELLANEOUS APPLICATION
[ Kreby affirm that I have a.certificate of consent to 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. C.)
,BUILDING [� �`��+,/+�vf
Rolicy;No. Company FOR APP.LICANTTO FILL IN ADDRESS
/ � 7 /Tv �/tel ��`s< I
❑.Certified copy Is hereby furnished. LDING
BUIJ
J - p fC/•I J. LOCALITY
-ADDRESS
❑ Certified Copy,is filed with the COunty,bulldlng Inspection - 1• - NEAREST •'- - -
LOCALITY • ST.
CROSS
department.. �:� 1 L
Date Applicant NEAREST `` /� DISTRICT NO. G UP TYPE' PRO SED BY
+ , CROSS ST. �rLL -��6/ - CONST./
CERTIFICATE OF.EXEMPTION FROM WORKIiRS' " ! LEGAL 5 • , ` Q/ - ,�,,,,
'DESCRIPTION LOT NO. BLOCK-,:•. FN
RIG.W.Y '}
COMPENSATION INSURANCE srwrE MAJOR SEC D,LOC
• _ _ - • (CIRCLE) -a,
F - • ♦ NO.OF BLDGS.; : : NE SPEC IAL'CONDITIONS O
(This .Section.need,not be Completed'if the .work mvUlved TRACT NOW ON LOT
by'the permit is for one hundred dollars'($100)•of less:) USE'OF -
SIZE'OF LOT - .EXISTING BLDG. -
I certify that irit`the'peifo'rmance of the work•ifor which,this O
„'•perrriit+is issued, I shall'nor'einploy'any,person in any`manner OWNER F-
so'as.to become,' to the Worker's' Compensation-La`ws. OCCUPANCY GROUP V'
- MAIL /y,- ..y• _ .IJJ
ADDRESS (,,I/' / �• � - " +,v _ _ a
Date Applic'anf,�`•" rn
NOTICE TO APPLICANT: If,.•after making,this Certificate of CITY �jq�J� Ivo ., a+ OCCUPANT LOAD _ Z
Exemption, you, should become.`subject tol.the' Workers;
= " APPLICATION•FOR EXIT HARDWARE:
Compensation provisions of the-Labor Code, you must•forth' ,
-with'comply`.with SUCK provisions or this permit-shall be TRAILER USE v GEOLOGY.,INSPECTION
deemed'ievoked. ❑. No Spec. Knowl. '❑
LICENSED CONTRACTORS DECLARATION: occuPwrvcY IrvsPEcnoN
Panic Devices ❑ ;
I-hereby affirm;that I.am licensed under provisions of Chapter sAFErY•PERMIr'Q `(LIST iTEMs BELOW)
NO. OF-EXITS
9 (commencing with Section 7000) of Division 3 of the Busi- i;.
ness,and Professions Code,_and my license is in full force anis ���' PARKING
effect- _ ' SPACES, REQ'D PROVIDED
License'Number Lie.Class
LIMITED TIME USE ,
•Cont}actor - .. ,Date DATE - - DATE
* FROM.
I am exempt from the licensing requirements as-I am-a, k.
licensed architect or a'registered professional engineer _ SIZE OF, NT F''_ 1 SPE CTO R'S
acting m my'••professional capacity (Section 7051,'BuS- EXISTING+BLOG. a, i STORIE S +S 3 NATURE
• 1nCSSand PiOfe5510(IS(,'Ode). ' • • 1 - PRESENT USE•o'F'BUILOING F;INAL'APPROVAL�
Lie.or Re'g.`No. Date
HOMEOWNER,-BUILD E R DECLARATION NO,;OF EXISTING BUILDINGS
, ON,L'OT AND USE •,A -
I .hereby affirm that' I yam exempt,'-from' the Con-tractor,'s
License,Law for the following reason'(Sect ion.ib31.5;-Busi=
ness and Professions Code): rvo. PARKING 'f
SPACES PROVIDED.
-I, as owner of,theproperty,;will do the work and the r K
structure is noY,'intended or offered.for'sale .(Sectiori •.� : - • ': .
i
7044, Business and Professions Code). 4 ;04805 A
•t• - •. PROPOSED USE',OF'BUII.DING
y I
CONSTRUCTION'LENDING'AGENCY
I hereby affirm that•4here-is a construction lending ageney ✓ J' ��� "1 t w# ° °.°•�'3 0
;for the performance of the work for.which this perm It—is i I ° ° 8 a 5 O
issued (Sec. 309,7,Civ.C.). _ :
Lender's Name s
f
PROPOSED MAX. OCC.' -
°:•:Ii8Q5,V:
'I'nder's,.Ad'dress PeRneir FEE
i
I certify that I have read this-application and state'that the ' 0'��� 2,`8 b
aboye'.information is correct.I agree to comply with.all County' ! sUANCE Fee 9
ordinances and State laws relating to building construction
-and hereby,authorize•re'presentatives-of this Couniy to enter, , TorA`L FEE S
upon, ab ov en neapty EVERSE FEXLANATORY-LANGU�AGE for inspection•purposes.' SEE ROR P� Gra d� - •-• . , . ,. _
i.7 ghat I "4
a of Permittee � .Da "" ,