HomeMy Public PortalAbout6247 KAUFFMAN AVE_Building__ • r:,
9dkERS'..COMPENSATION DECLARATION
1 hereby affirm that I.have a certificate of consent to self
insure, pr o'certificate of Workers Compensation Insurance, APPLICATION FOR UIL DING PERMIT
5r a,c&tified copy thereof (Sec. 3800, Lab. Com�.••) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. 6-15-1"—Company mpany*N'V-F' OJD-
_9/ BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS .
Certified copy is filed with the county building inspec- BUILDING f/
tion department. ADDRESS - & P!O
HISCI�
TY' €i G ZIP717LOCALITY �v C
Date 9 Applicant �r�a� �D ?- / O. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT o�3 NOW ON LOT CROSS ST. G O
T�
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK d PAGE /Co PARCEL
hundred dollars ($100) or less.) G Cf @ O C 7016— USE ZONE MAP
OWN - 1J9 �5�3/NT.�10. NO.
I certify that in the performance of the work for which This �/�J. SPECIAL
CL
permit is issued, I shall not employ any person in any manner ADDRESS 0 1A CONDITIONS O
so as to become subject to the Workers' Compensation Laws. U
CITY ZIP
Date Applicant ARCHITECT 0 TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Q.E/j/L(//�LG �SSOe.N0.3SI- SSI COQ_ ZONE
Exemption, you should become subject To the Workers' p ' / w
Compensation provisions of the Labor Code, you must forth- ADDRESS4�O
with comply with such provisions or this permit.shall be STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR C—p NO. / Z /Z �J' Z
LICENSED CONTRACTORS DECLARATION G ..��� LIC. CLASS NO.�DwELL. UNITS
ADDRESS S / 1J12b ,7I NO.
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.;, ' , /
and Professions Code,and my license is in full force and effect. CITY�/} �(�/p1� 9233exLA55 BK L- PG / < VALIDATION
(I q SQ. FT. NO. OF NO. OF CHECK
License Number /9�Z61 Lic. ClaLs�s SIZE STORIES FAMILIES ONE VALUATION kit•!_•, ,
Contractor ��� CoNs�• Dare ` DESCRIPTION OF WORK ev NEW ❑ „.y
ADD
❑ S ODD• 00 _ „c a a_ .•. %,
❑I am exempt under Sec. ALTER �� eO0•oa � i i 'siZ=
BAP.C: for this reason ��G ,G� /LE7r J�'�7/r! f — q __ ��*
REPAIR ❑ 9 E'-„IIAL ss.:. Fa 4-2
Date: EXISTUSE ING BLDG. �yG/�G°� \ DEMOL ❑ y/� OdD Oil TO _
1L!:i �-a
Signature APPLICANT /J TEL �t, t�•
g (PRINT)( /gLG NO.,� �-S.Jo2 FINAL
OWNER- ILDE EC ATIOhf DATE
I hereby affirm that I am xem t from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS Ipc! oS�Ei>°�/j /� �� G�/GGA FINAL .�
Professions Code): PRESENT BY ,�,�y'? iI_i`si� ;`_:
BUILDING
El 1, as owner of the property, or my employees with ADDRESS �” - "`
wages as their sole compensation,will do the work and =-sg
the structure is not intended or offered for sale(Section LOCALITY f - :=
7044, Business and Professions Code.)
MOVING TEL. = i'1'\"
t.= c=,^��::z
E] 1, NO. DOT I, as owner of the property, am exclusively contractingr;i __e,� _
with licensed contractors.to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) . 5*1 7c-5.1s.
REQUIRED TOTAL SETBACK FROM EXIST. (.'H Cil. _
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT s_
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
/ LDMA Ref. #
P.C. Fee$ x ' Permit Fee
Lender's Address
0
1 certify that I have read this application and state that the Issuance Fee 1-5• LDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee i
R ordinances and State laws relating,To building construction, Total Fee %0 LDMA Perm. #
a and hereb authorize representatives of this County to enter
upon t e b e- nfioned,,3property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature qffApplicAt or Agent Date .