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HomeMy Public PortalAbout6002 AVON AVE_Building_6/13/1991_reroof -" WORKERS' COMPENSATION DECLARATION insure,oraffirm that te of Workers' Compensation Insuran e, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. - Company BUILDING © Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS O w. ❑ Certified copy is filed with the county building inspec- BUILDING 0 Al/D tion department. ADDRESS !/r e AA-,AA-, Le CITY ./ I P LOCALITY Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. OWNER NO: - USE ZONE M�+P I certify that in the performance of the work for which this SPE permit is issued, I shall not employ an person in an manner ADDRESS SPECIAL } p p y Y p y CONDITIONS a so as to become subject to the Workers'Compensation Laws. O CITY Q ZIP U Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. Z NE Exemption, you should become subject to the Workers' _� r / w Compensation provisions of the Labor Code, you must forth- ADDRESS i�(� �/ a with comply with such provisions or this permit shall be _h NL STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR fJ"� _ LIC. CLASS No. DWELL. UNITS LICENSED CONTRACTORS DECLARATION ADORES T� NO. � 1 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 (tf �- CLASS BK. PG. VALIDATION 7 SQ. FT. NO. O NO. OF CHECK License Number S2 ITE ZLic. Class/= J 9 SIZE STORIES FAMILIES ONE. T ON VALVA Contractor (L�� '�� Date v �v^!/ DESCRIPTION OF WORK NEW ❑ $ ((��////'' ❑I am exempt under Sec. L ADD ❑ ► s •':tos ALTER ❑ B.BP.C. for this reason ❑ _ '=`- US OF02 REPAIR S D e: - EXISTING BLDG. DEMOL 01 s,6_i F -s Signature APPLICANT L TEL. 1_. 116 � 8 g O E -BUILDER.DE ARATION (PRINT) N0.3�I' FINAL/Ci14� t{ A'� DATE I hereby affirm that I am exempt from the Contractor's License gDDRESS 3 e6e ffv O Law for the following reason (Section 7031.5, Business and FINAL J '_:In>'NGE ,I_j(_I Professions Code): PRESENT By BUILDINGEl 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 and Professions Code.) MOVING TEL. poll _741,_1� ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project.(Sec- ADDRESS tion 7044, Business and ProfessionsCode.) CONSTRUCTION LENDING AGENCY SETBACK YARD HWY TOTAL SETBACK LINE FROM WIDTH i 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 P.L. Lender's Name nO fiQ LDMA Ref. # Lender's Address P.C. Fee$ Permit Fee O O 3 . , 0o 1 certify that I have read this application and state that the IssuanceLDM Fee 4'fJ A P/C# above information is correct. I agree to comply with all County Investigation Fee ' R ordinances and State laws relating to building construction, Total Fee �• LDMA Perm. # a and her y authorize represe of this'County to enter upon a bove- a tione op for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ippikcant or Agent Date