HomeMy Public PortalAbout6110 AVON AVE_Building_7/29/1957_reroof WORKERS' COMPENSATION DECLAR TION
insure,hereby
a certificate of Worke4-Comtpen`s,o�s i su�ancA P P L I CATION FOR BUILDING' PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.)
?rPS-9� COUNTY OF LOS ANGELES BUILDING AND SAFETY
o
Policy No. Company
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 1p//4,
Certified copy is filed with the county building inspec- BUILDING /`�� �dOrrJ
tion department. AhDDRESS
te —'� �� p tcan�f� �
CITY i�//� N��Cr� ZIP LOCALITY f
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM.WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
GOMPE-NSPrT-ION'1NS RANCEASSESSOR
(Thi ection need not be completed if the pe it is for one TRACT BLOCK LOT NO. MAP BOOK PAGE I PARCEL
hundre ollars ($100) or les �y�,��• TEL
OWNER ii/ic,�, �J?,gLD�E. NO,��' USE ZONE MAP
--I-certify that i he performance of th work for which this NO.
permit is issued, all n n-irra»y 3aanner ADDRESS ���® ��0 SPECIAL
so o ec'ommegsuu I to the rkers' Compensation Laws. CONDITIONS O
. /J CITY J/div 6,.V0WX-6-zip U
Date A tca ARCHITECT OR TEL. W
NOTICE TO APPLICA If, after this Certificate of ENGINEER NO. DISTRICT GROUP TTYP icc T ERNE PROCESSED BY O
Exempption, you ould become �a�king
ct t the Workers' G �.Com ensation visions of the Labo ou must forth- ADDRESS l/ a
with m I mit—shall be - TEL N
deemed r oked. CONTRACTOR Q__ STATISTICAL CLASSIFIC TION APT. CONDO.
�.4�iC0/51 �, NO.e'z���1d/� Z
TION LIC. CLASS NO. DWELL. UNITS
—
ON hereby affirm that I am licensed under provisions of Cha 9 ADDRESS ���1 �� ✓i4,� /¢lNO. �/,��3�8
(commencing with on 7000)of Division 3 of the Busines
LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY /E/ ,001eo e/�G CLASS G1`7 BK PG VALIDATION
3'� SQ. FT. NO. OF_ NO. OF CHECK
License Number 7 Lic. Class -3� SIZE STORIES FAMILIES ONE
VALUATION
Contractor //4u,C 1-y �1 Date 2-26—�'3 DESCRIPTION OF WORK �T ,e O« NEW ❑ $ ? O iI�G1G7
❑I am exempt under Sec. F2 .ADD ❑ / `7 ► .
? �J ✓ LTER ❑
B.&P.C..for this reason _ '�" - �'Z�r�jf�Sf �� ! REPAIR ❑ $
ate:
EXISTING BLDG. ` DEMOL ❑
Signatu J / _' (PRINT)
L. FINAL
/ i
ILDER DECLARATION ) N S JO/I
a .....DATE- . . .Z-..' G' ..... ..... _..- a -
I hereby affirm that I am exempt from the.Contractor's License ,ftp —fir I °Ir
Law for the following reason (Section 7031.5, Business and ADDRE r �7ti FINAL ^e�yf
Professions Code): PRESENT �kJ
By .`l+ ITEMS
BUILDING /�A /4�0� f
❑ I, as owner of the property, or my employees with ADDRESS 1
wages as their sole compensation,will do the work and -"" t
the structure is not intended or offered for sale(Section LOCALITY ► TOTAL :L17 ®90
7044, Business and Professions Code.) MOVING TEL,CONTRACTOR
{ 411 '
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. CHECK 11'
with licensed contractors to construct the project (Sec- ADDRESS CHANGE .00
tion 7044, Business and Professions.Code.)
.REQUIRED TOTAL SETBACK FROM EXIST. "-
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH _
rT
I hereby affirm that there is a construction lending agency for FRONT j �( -( � 3 ?�+
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE ` sM 9..
P.L.
Lender's Name
9 LDMA Ref. #
P.C. Fee $ Permit Fee /
Lender's Address ^ 0111
0 1 certify that I have read this application and state that the Issuance Fee d• LDMA P/C#
above information is correct. I agree to comply with all.County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee o / LDMA Perm. #
a and hereb rize representatives of this County to enter
upo a ov entio d property for inspection purposes.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnoture of Applicant or Agent Date