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Home My Public Portal About6031 AVON AVE_Miscellaneous__ WORKE S'COMENSATION DECLARATION CE 8754(„-84) MISCELLANEOUS APPLICATION I hereby affirm that i have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS FlCertified copy is hereby furnished. Bu1LDING d LOCALITY DRESS AD ��. ❑ Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. TYPE PROCESSED BY CROSS 'O� [,,GROUP - 3 CONST. � � CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT 2 NOW ON LO7 USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. d I certify that in the performance of the work for which this I o permit is issued, I shall not employ any person in any manner OWNER 4) 2K] =) so as to become subject to the Workers' Compensation Laws. MAIL �� Q/ ��D/ OCCUPANCY GROUP o Date Applicant ADDRESS �jo (�/�/I� //£, U LLI rEL' OCCUPANT LOAD o_ NOTICE TO APPLICANT: If, after making this Certificate of clrY � L No. Exemption, you should become subject to the Workers' _ Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be deemed revoked. TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices 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 /I r nn effect. LA�� IF I,5 { 43L O Ike- PARKING � Pr SPACES REpID D PROVIDED D License Number Lic. Class v Jf-e- •T 1 rJopclir pp 0 r4 LIMITED TIME USE Contractor Date &d 0 0& 54y<_c_oI6%)P_A4eA 6 DATE DATE El �IKROM: I am exempt from the licensing requirements as I am a LL , C�O �14.�-Q►GQ. t4� TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES t SIGNATURE iness and Professions Code). Lic.or Reg.No. Date PRESENT USE OF BUILDING GS 9 VA)7 FINAL APPROVAL HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 0A/[_ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi r' ness nd Professions Code): NO.PARKING _, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section I - � 7044,Business and Professions Code). :l1 Ei -.7- 7 m CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING�0��'F ? w_ I hereby affirm that there is a construction lending agency All k U%1 ..�2 �cj��I`JJ C'A-N`a= X91 for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. � P' A) s�Q�G�i7::al M p Lender's NameW AS CJ QsYi..' PROPdSED MAX. OCC. •• - Lender's Address PERMIT FEE ,C" •:'-i'-.� z I+ 1-. :_ I certify that I have read this application and state that the 'L above information is correct. I agree to comply with all County ISSUANCE FEE o?rf 7 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE / upon eabove-mentioned pert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signa ure of Permittee 'Date WWKERS'COMPENSATION DECLARATION CE 876 (t 1+84) 1 MISCELLANEOUS APPLIC TION I hereby 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.Q. Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ BUILDING - Certified copy is hereby furnished. 6 1 LOCALITY ADDRESS i 0 Certified copy is filed with the county building inspection LOCALITY 603SAN GN. AVO NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT NO. GROUP TYPE PR ESSED BY CROSS ST. N�USCATEL '� ry JJ 3 CONSTV CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL !J! �./Ci COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NOOF LOGS. (This Section need not be completed if the work involved TRACT NOW. ONBLOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT 5,400 EXISTING BLDG. I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER James and Adrina Hardin c� so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP _3 CI-1.D eesS 1000 RICH ROAD o Date Applicant W TEL.(901) 465-4893 OCCUPANT LOAD o NOTICE TO APPLICANT: If, after making this Certificate of CITY TEMOSSE No. C/, Exemption, you should become subject to the Workers' Z Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be deemed revoked. TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT E] (LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code, and my license is in full force and -I effect. SPA PARKING REQ'. C I PROVIDED SPACES J License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a PROM. TO. licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES I SIGNATURE iness and Professions Code). 1,414 OUSE FINAL APPROVAL ,,f Lie.or Reg.No. Date [i7��'C PRESENT USE OF BUILDING Sin le family �41 oofge - I 1W HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): No. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED � structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby,affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address � PERMIT FEE L �� 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 represeutatives of this County to enter TOTAL FEE upon the ab ve e rty for insp ctiorwurpops. SEE REVERSE FOR EXPLANATORY LANGUAGE ��Signa of,?erm ittes�r ,� /firate '