HomeMy Public PortalAbout6229 AVON AVE_Building__ WORKERS' COMPENSATION DECLARATION
insure bor affcertif catte'have a ceritificate of of Workers
o ke s' Compensation eInsuran 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 6-z-2,q AvoAl 4yc
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS ' S"
CITY �+� ZIP J 1-7757-
LOCALITY
Date Applicant NO. OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF.LOT ' NOW ON LOT NEAREST
CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOKPAGE 0 0 PARCEL
hundred dollars ($100) or less.) TEL. T" MAP
OWNER ^�.. NO. USE ZONENO.
I'certify that in the performance of the work for which this SPECIAL }
permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS
so as to become subject to the Workers' Compensation Laws. O
CITY 5,44 6"ejaL ZIP f U
Date Applicant ARCHITECT OR TEL. �
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY
CONST. ZONE �
Exemption, you should become subject to the Workers- /J 2
Compensation provisions of the Labor Code, you must forth- ADDRESS ��/� /C J w
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. _
LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I'am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP
and Professions Code,and my license is in full.force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE STORIES FAMILIES ONE
El VALUATION
Contractor Date DESCRIPTION OF WORK NEW a
ADD ❑ poll.CQ—
I am exempt under Sec.
ALTER ❑
B.BP.C., for this reason REPAIR $
USE OF
Date: EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL.
g 57(bg6 FINAL _ 9
OWNER-BUILDER DECLARATION DATE
(PRINT) NO
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and ADDRESS Z �� FINAL �A
r�of/essions Code): PRESENT
r ByBUI
I I, as owner of The property, or my employees with ADDRESS -�
wages as their sole compensation,will do the work and ► C; +'}._e;
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL. a r_ I'.:
E] 1, as owner of The property, am exclusively contracting CONTRACTOR NO. t — �_
with licensed contractors To consiruct.ihe project (Sec- ADDRESS
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST. "�=6
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT = H I-
'U 1=t
the performance of the work for which this permit is issued P.C.
(Sec. 3097, Civ. C.). SIDE",
P.L.
Lender's Name
LDMA Ref. # y I_I
Lender's Address i t _
P.C. Fee$ Permit Fee r I -
,1 certify that I have read this application and state that the Issuance Fee LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
8
ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
a and hereby authorize representatives of this County to enter
cupon the above-menti o d propeirty for inspection urp ses.
d ��Gyj &/-f Iq
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Applicant or Agent Date