HomeMy Public PortalAbout6139 KAUFFMAN AVE_Building__ { APPLl TIO. FOS UJ ING PERMIT
COt 1NTY OF LOS ANGELES - , � BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR,_APPLICANT TO FILL IN — BUIL ING ADbRESS
I hereby affirm that I have a certificate of consent to self insure, BUILDING AD R Ss `y,� ,
or a certificate of Workers' Compensation Insurance,or a certified Aa " ' 3AVr�
copy thereof (Sec.3800,Lab.C.) CITY j! ZIP
G H GSL / 7(�O LOCALITY
Policy NQ/�.�9®�� Compan L
SIZE OF LOT NO.OF BLDGS.NOW ON LOT
Certified copy is hereby furnished. 19 d X( U Q( NEAREST CROSS ST. AV
❑ Certified copy is filed with the county building inspection TRACT BLOCK- LOT NO.
department. / USE ZONE MAP NO.
Date Applicant/Lw L�� ASSESSOR 1_318 , PAG j7 PARCEL
✓C p"v SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWN% �fl u�� TEL O. �6 /
COMPENSATION INSURANCE O WITHIN 1000 FT OF SCHOOL? YES NO
This section need not be completed if.the permit is for one hundred ADDRESS �J
( P P 6 r rl - DISTRICT GROUP TYPE CONST. FIRE ZQN.E.. P�iOCESSED BY
1
dollars ($100)Or less.) CITY j ZIP '`
I I certify that in the.performance of the work for which this permit LAV? l- r vo
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO.
become subject to the Workers'Compensation Laws. G STATISTICAL CLASSIFCATION APT CONDO T
Date Applicant ADDRESS / A 7 7 CLASS NO. e2 DWELL UNITS � -.
NOTICE TO APPLICANT: If, after making this Certificate of "K�72 7 �! REQUIRED TOTAL SETBACKTROM- EXIST
Exemption, you Should become Subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PR0,Pj—q E
Compensation provisions of the Labor Code, you must forthwith /fes:♦ i%vim` C /� �-12 5; FRONT
comply with such provisions or this permit shall be deemed revoked.. N ADDRESS �+C_ LIC.NO. P L + ,±' tt +'-i =s(
;�� --s
2C S Z. la /Z4a'� i_I
LICENSED CONTRACTORS DECLARATION CITY ( LIC.CLASS L PIDE :. ;J
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(Commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES
NEW: BK PG - i r7 t c }
Professions Code,and my license is in full force and effect. `L Zj� Q Z , j:j ;) I-" i r ,• a
License Number Lic.Class 1M� DESCRIPTION OF WORK' ADD' ❑ VALUATION `.
Contractor +� Date P `� 2` s
"f❑
ALTER
f► Z5 20 X Za' REPAIR ❑ $ / B�-�, _ i=; =`, ''^0
B.&P.C. for this reason DEMOL ❑
i
Date: USE OF EXISTING BLDG: URM ❑ LDMA P/C# - _ -` •- _Y W
Signature APPLICANT(PRINT) TEL NO. LDMA Perm#
„;f a-.:7',
El 1, as owner of the property, or my employees with wages as 7v rSa3 5- P Z V•
ADDRESS O -UAJi__
their sole compensation, will do the work and the structure is �.(1 �y 2 � �•::-:t s=3s_ __..
not intended or offered for sale (Section 7044, Business and 'y - /• 4,A- 41 1 FINAL DATE
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE •^- -"- q + .r :,
❑ I, as owner Of the property, am exclusively contracting with AMOUNTS
SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project (Section 7044, YES❑ NO❑
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ No❑
w the performance of the work for which this permit is issued(Sec. C-I F;:') "'i i C••t ,
rn I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND Vdi£SMMD PERMIT_ 0 ,•^• l.�,l �.
w 3097, CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANSDE499 COUNTY G
TITLE 2,CHAPTER 2.20 SECTIONS 2.20.700 THROUGH 2.20.140 GEkyCNG HAZARDCt7 .,
3: Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAdfelb.
EL Lender's Address
O OWNER OR AGENT
0 1 certify that I have read this application and state under penalty r+j
o P.C.FEE PERMIT FEE ry
of perjury that the above information is correct.I agree to comply `� ��,,, �p � =•a:
with all county ordinances and State laws relating to building J
CO construction, and hereby authorize representatives of this County n ISSUANCE FEE :�j• ._ ^I
to enter upon the above-mentioned property for inspection purposes. %
� •��;,� 1 INVESTIGATION FEE TOTAL FEE ;,�.,
SEE REVERSE FOR EXPLANATORY LA!4GU'A6E I-+"•1 "••i