HomeMy Public PortalAbout6272 AVON AVE_Building__ ORKERS' COMPfI);:,A'fION DECLARATION
I her6by' affirm that I have a certificate of consent to self ® ,p
insure, or cwtifi,' t":'a;'1;'orkem' Compensation Insurar_e, p�15f1J' PJ' �� ATI®N FOR BUILDING PERMIT
or u,certified copy.,.,ereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS 7--
Date Applicant CITY J JH 7 / ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' O.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT '? O 1 ' NOW ON LOT CROSS OR
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. ) MAP BOOK PAGE PARCEL
USE ONE MAP
I certify that in the performance of the work for which this OWNER r AP
permit is issued, I shall not employ any person in any manner / ?/ .: - ! 1ASPECIAL
ADDRESS
so as to become subject to the Workers'Compensation Laws: CONDITIONS
Date Applicant � G
CITY ZIP
ARCHITECT.OR TEL.
NOTICE TO APPLI ANT: If, after making this Certific to of DISTRICT GROUP TYPE FIRE PROCESSED BY
ENGINEER NO. CONST. ZO
Exemption, you should become subject to the Workers' �',t(� �T'�, ,p
Compensation provisions of the Labor Code, you must forth- ADDRESS `�lU �f
with comply with such provisions or this permit shall be
deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. CONDO.
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. 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 and LIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION �.
SQ. FT. NO. OF �f NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE (Q
VALUATION ,/� / U
Contractor' Date DESCRIPTION OF WOO NEW ❑ $ � ✓fL ,�/. /�
7 ADD / /v / (V� , O
I am exempt under Sec. W C;) '� l •"
ALTER ❑ _ U
B.&P.C. for this reason Z t
REPAIR ❑ $ LL
Date: USE OF - ❑ �/ !J. _ .. '.`ice
EXISTING BLDG. DEMOL
Signature APPLICANT r
OWNER-BUILDER DECLARATION PRINT) y } NOTEL_ 1� . FINAL
DATE _..._:.., • _.
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS - r - FINAL
Professions Code): PRE ENT
BUILDING c•:•;;,[,a,
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY �:-
7044, Business and Professions Code MOVING TEL. �«`f;
/ {t....i:".'., is
I, as owner of the property, am exclusively contracting CONTRACTOR NO. / "` _-
with licensed contractors to construct the project (Sec- ADDRESS
y. ...
tion 7044, Business and Professions Code).
REQUIRED
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTAL SETBACK FROM PROP. LINE WIDTH ' r.;,_•_;-.L; _ ,;:w:
.I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
;;
Lender's Name �:i•-. ;•;•;, .,t;:= �•;••
.�- LDMA Ref. #;•:I -"'
p Lender's Address P.C. Fee$ 767,2-K PermitFee g �- - --i` -_- -- ''••
`v
o I certify that I,have read this application and state that the �i®� Issuance Fee d LDMA P/C# �':_'
a
above information is correct. I agree to comply with all County Investigation Fee
o ordinances and State laws relating to building construction, Total Fee ��
N and hereby authorize representatives of this County to enter LDMA Perm. #
Up on t above-mentioned property for inspection purposes. _!; r, �•�
p...
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or ent Date
li c°ARTMENT OF BUILDING AND SAFETY APPLICATION FOR PER3ft x
.)
COUNTY OF LOS ANGELESX. CHIEF ENGINEER BUILD NWM. J. FO I
NO. BLDG.
PLANES ORD. NO. DISTRICT NO. PLAN CK. NO. ERMIT NO.
SETBACK LINE •�---••
FIRE APPROVED �+� S3 Z14 ,
ZONE BY DATE
RECEIV D DATE OF /PPL. DATE ISSUED
USE APPROVED �I✓�
ZONE BY DATE ! r 7- 40
APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY
BUILDING
ADDRESS /� ,Na -4 yh
U v r'r' ♦ r
hW- u ADDRESS LOCALITY
KU W CITY ` /� t �. NEAREST ----��.�
CROSS ST. LD /
STATE TEL.
LICENSE NO. �. NO. W NAME /�i� / • "} :�, 'r f _
ar C NAME T f /-'.� ! ; MAIL
FO I 0 ADDRESS +� , //7
t
< ADDRESS /i , TEL
CITY /: .. I NO.
Z
0 CITY 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS
U STATE / APPLICATION AND STATE THAT THE ABOVE to CORRECT
LICENSE NO. ,F .♦^ NO(r( / �• r - AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING BUILDING CONSTRUCTION.
2
OLOT. NO_(y /n1 SIZE OF LOT x /DO SIGNATURE OF
J 1 OWNER
NO. OF OLDGS.
BLOCK Nn AN r t1T /N AUTHORIZED AGT.
rYY."""•�1.!�J's7%�!•>N iiW�.'�lq k!:.�W,J•'.M."M:;�;.M.f�•`y�•�.Y.�♦ :�•/� A
�. � J UI «Mrf.tMisr.•..:• �;;;!'S!%I`,Ai'.f�i7�r�::�.+�r!+.;a!!tL!► Y•t.Svi•/1:��'3•7�r•n."i�► �*3 �.awsi;i,'
WCORIZECTITONS
T?,1GT v � J `l
r OI !USE OF BLDGS.
NOW ON I.OT
•N�Y•�_.Y'�'11 ;C+�Lt1a.Y.:'IVT^V1-A'{tT�S'. '^(•Y \il. (.A.1fM. ." .'1
. . �.. .. . .. -j..r.r.T�~i�?,���1.�.•��i...��R;c.�.J•T�:�+�n'r!r'.r... ..Y+'`, .:�.w�.�y...►/'r�: %as'~ ...'.. �.. . .r.q...•,^�. •i--.........q.�.••.sY,.t�..,,.... ,`
►. USE OF
BUILDING / ,yam
c� 47
]41
m J
.r Z
^`1 ✓/ fes... .
{I Q'
TYFF r unOUP
I NO. OF NO. OP
4 ALTERATION ROOM8 'FAMILIES
ADDITION SIZE ..
REPAIR STORIES
t MOVING WALL COVERING—
J�
DEMOLfbH ROOF COV, RING--- • �L
/ S FEE s u FINAL APPROVAL
s Q v
/ INSPECTOR'S
VALUATION FE �'?` yDATE/�''7
NAME