HomeMy Public PortalAbout6219 AVON AVE_Building__ r �
a WORKERS COMPENSATION DECLARATION
4reioy affirm that I have a certificate of consent to self APPLICATION F O U I L D I N G PERMIT
inarre or a certificate of Workers Compenstion Insurance or
o certified copy thereof (Sec 3800 Lab C ) _ COUNTY OF LOS AN LES C BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING 9 b
� ADDRESS
`Certified copy is filed with the county building inspec BUILDING / a r�
S tion department ADDRESS (Q t 1 ��� LOCALITY
NEAREST
Date Applicant CITY ZIP CROSS 5T C�LJ j�J�f
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSOR
-- ' COMPENSATION INSURANCE - SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one ! USE ZONE
hundred dollars ($100)or less ) TRACT BLOCK LOT NO
TE '7 SPECIAL d
I certify that in the performan oft wo k for which this _ 1 OWNER N �✓ CONDITIONS O `
permit is issued I shall not empl any rso in any manner c� DISTRICT GROUP TYPE FIRE P ED BY (�
I ADDRESS SOS �/( �� CONST ZO
so as to become subject to the W
L
C ns tiQ\t L�a�w�,s ,0 O ®C
Date �'v Applicant -- CITY ZIPR�UC/ STATISTICAL CLASSIFICATION APT CONDO V
NOTICE TO APPLICANT If after making this Certificate of ' ARCHITECT OR TEL W
Exemption you should become subject to the Workers ENGINEER NO CLASS NO DWELL UNITS N
Compensation provisions of the Labor Code you must forth
ADDRESS SEWER MAP
with comply with such provisions or this permit shall be t —
deemed revoked CONTRACTOR TEL BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION /�
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC � rr
Professions Code and my license is in full force and effect CITY CLASS $�, ®
I SQ FT NO OF NO OF CHECK
License Number ' ` Lic Class ) SIZE STORIES FAMILIES ONE
$
Contractor i Date DESCRIPTI NOF WORK NEW
I am exempt from the licensing requirements as I am a ADD y
licensed architect or a registered professional engineer A F` � q \�. ALTER FINAL
acting in my professional capacity (Section 7051 r h/ REPAIR DATE ( �(
Business and Professions Code) USE OF rt�� :
EXISTING BLDG e /���(�If� DEMOL FINAL
By
Lic or Reg No Date APPLICANTEL
OWNER BUILDER DECLARATION (PRINT) PI. O
24Xf-1 S1
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and ADDRESS 110E�o ,jCazQPVAa
Professions Code) BU MI
BU MING s
I as owner of the property or my employees with ADDRESS
wages as their sole compensation will clothe work and/ kADDRE
_ zs 2 9 0 A
the structure is not intended or offered for sale(Section
7044 Business and Professions Code) TEL {
I as owner of the property am exclusively contracting TOR NO # 0 0 0 0 0 1 `
r with licensed contractors to construct the project (Sec
tion 7044 Business and Professions Code) I _ r 2,o o 22 00
ED TOTAL SETBACK FROM EXIST 2 2 O O v
CONSTRUCTION LENDING AGENCY v K YARD HWY PROP LINE WIDTH - o to o =
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued - I 1 05-80
(Sec 3097 Civ C )Lender s Name
Lender s Address _ Permit Fee/L� Y
a
wI ertify t I have read this application and state that the Issuance Fee 7,
aa ve in Frm n is correct I agree to comply with all County Investigation Fee - -
0 or nanc and tate lows relating to building construction Total FeeO� „Pd
a here utho ze representatives of this County to enter
m
u thea o m nti ed property for inspection purposes f
d
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date Os