HomeMy Public PortalAbout6040 AVON AVE_Building_6/9/1987_reroof WORKERS COMPENSATION DECLARATION s s M1
• +nsureboraafirm that certifca"tee of have Compensatoificate of nent to se
Insuran elf 1 T - APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C ) (� V t Ra i*
COUNTY OF LOS ANGELES BUILDING AND SAFETY a
Policy No � �( Company
El
Certified copy is hereby,,furnished f FOR APPLICANT TO FILL IN BUILDING ADDRESS (p a Q
Certified copy is filed with the county bui g mspec BUILDING /J �q �j " *'" "
tion department ADDRESS j
Date `'Applicant CITY ZIP t LOCALITY t
CERTIFICATE OF EXEMPTI FRO ORKERS " NO OF BLDGS NEAREST
COMPENSATION INSURANCE 9 SIZE OF LOT NOW ON LOT CROSS ST
(This section need not be completed if the permit is for one _ ASSESSOR
hundred dollars ($100)or less )y a TRACT BLOCK LOT NO MAP BOOK , PAGE PARCEL
w a t OWNER NO TEL USE ONE OP
I certify that in the performance of the work for which this l
permit is issued I shall not employ any person many manned " , / SPECIAL
so as to become subject to the Workers Compensation Laws ADDRESS 1 CONDITIONS 0
Date r " Applicant AOR TELITY ARCHITECT h ZIP
NOTICE TO APPLICANT If after making this Certificate of - DISTRICTG OUP TYPE FIRE Z�SED BY
ENGINEER NO
Exemption you should become subject to the Workers -2 CONST s ZQNE U y
Compensation provisions of the Labor Code you must forth ADDRESS
a [OY] J ,'�//t Lil
with comply with such provisions or this permit shall be + TEL ; D
deemed revoked STATISTICAL CLASSIFIC ION APT NDO to
M1 �� �' ` CONTRACTOR NO 6 Z `
LICENSED CONTRACTORS DECLARATION ` F / LIC CLASS NO v DWELL UNITS
I hereby`,affirm that I am -JO under provisions of Chapter 9 ADDRESS /rca ' NO A/7 / SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and + LIC 4
Professions Code and my license is in full force and effect CITY CLASS CBK - VALIDATION
n SQ FT NO OF NO OF CHECK
License Number / Lic Class PG
SIZE < STORIES FAMILIES ONE t t
t " t y7 4 VALUATION
Coniractor��1.Co�. Date DESCRIPTION OF WORK- - NEW Q $ 17
ADD /
I am exempt under Sec � -
` ALTER
-01,
B&P C for this reason - — IY REPAIR Q $ " r
` Dat `v USE OF _ {
EXISTING BLDG DEMOL
aW APPLICAN °' TEL
"
Signature �t PRINTT t - NO FINAL ;2 7 2(1 2 A
NER BUILDER DECLARATION DATE
1 hereby affirthat I am exempt from the Contractor s License a
y Law�for the following reason (Section 7031 5 Business and ADDRESS FINAL
r Professions Code) *A AF 7- - x — By
BUILDING 4 ° Q 3 r r [
I as,owner of the property or my employees with ADDRESS.
wages as their sole compensation will do the work and •1° Q 6f
3 ca):
the structure is not intended or offered for sale(Section t LOCALITY a ® _
7044 Business and Professions Code) MOVING - TEL "` -10609-87
I as owner of the propertyt'am exclusively contracting CONTRACTOR` NO 1 k
with licensed contractors to construct,the project (Sec-
tion
Sec
tion 7044 Business and Professions Code) ADDRESS ' s
+ a `' '" ' 4 REQUIRED„ i " TOTAL SETBACK
A CONSTRUCTION LENDING AGENCY y SET BACK YARD HWY PROP LINE �� WIDTH j+ a
I hereby affirm that there is a construction lending agency for FRONT
�F the performance of the work for which this permit is'issued P L ` }
(Sec 3097 Civ C ) 11 - 9 ' SIDE r t
PL g r
b
Lender s Name
* ' r LDMA Ref #
P C eFee$ ,�-+ Permit Fee
Lender s Address _
� /t//�� z
o _1 certify that I have read this'application and state that the ' t Issuance Fee /V[.� LDMA P/C#
o above information is correct I agree to comply with all County Investigation Fee ` x / / yv 1 f
0 ordinances and State jaws relating to building construction , ee �/(� LDMA Perm #
and reb orae representatives of this County to enter Total F
upo he r ve entioned property for inspection purposes ti
m r a _
' x l ' $ SEE REVERSE FOR EXPLANATORY LANGUAGE/77 ' r
Signature of Applicant or Agent 1 Date _
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