HomeMy Public PortalAbout6132 KAUFFMAN AVE_Miscellaneous__ WORKERS COMPErISATIOPF DECLARATION
CE 875 (17-84) MISCELLANEOUS HPPLICHTION
I hereby affirm that I have 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.Q.
Policy No. Company FOR APPLICANT TO FI LL IN BUILDING
_ ADDRESS
Certified copy is hereby furnished.' XBUILDING /�� 4
' ADDRESS GIS L� `4�J LOCALITY
Certified copy is filed with the county building inspection LOCALITY NEAREST
department. CROSS sr.
Date Applicant NEAREST DISTRICT NO. 1 GR UP TYPE. R ESSED BY
CROSS ST. ^/y CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (fid
COMPENSATION INSURANCE DESCRIPTION LOT No. BLOCK MAP, %HIGHWAY
No. (CIRCLE) STATE MAJOR SECOND LOCAL
' NO. OF SLOGS.
(This section' need,not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
1
I certify that in the•performance of the work for which this SIZE OF LOT EXISTING BLDG.� o
permit is issued', I shall not employ any person iii any manner OWNEe
so as to become subject to the Workers •Compensation Laws. MAIL OCCUPANCY GROUP _
�'] 0
ADDRESS /�oC �• gLe2.,sv �� U
Date Applicant u,
TEL _ OCCUPANT LOAD ;
NOTICE'TO APPLICANT: If, after making this Certificate of CITY No. ��
Exemption, -you should become subject to the Workers' APPLIC ION 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. I El
- - Panic Devices
LICENSED CONTRACTORS DECLARATION ' OccurANCY INSPECTION
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. OF Exlrs
ness,and Professions Code,and my license is in full force and
effect. D PARKING REQ'D PROVIDED
SPACES
License Number Lic. Class LIMITED TIME USE
Contractor Date o? 70p DATE DATE
•� FROM: TO:
I am exempt from the licensing requirements as I am a oS
licensed architect or -a registered professional engineer SIZE OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL 6-
PRESENT USE OF BUILDING /
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION N F EXISTING BUILDINGS I
O ,LOT AND USE 1' ITEMS
I hereby affirm that I am exempt from the Contractor'si E,i T 41 34 m -� 5
License Law for the following-reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING - CHEr""
ElI, as owner of the property, will do the work and the SPACES PROVIDED ,CHA
structure is not intended or offered for sale (Section �aE '` -
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING r �i I
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is t 1 1 All i.1'24
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC. ,
Lender's Address �J
PERMIT FEE
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 -
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE • O� S
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE.' '
Signature of Permittee Date