HomeMy Public PortalAbout6273 AVON AVE_Building_3/13/1992_reroof WORKERS' COMPENSATION DECLARATION 1
I have a certificate of consent to se
insure,boraa certififfirm tcalte of Workers' Compensation Insuran of APPLICATION FOR BUILDING PERMIT.
or ce c h (Sec. 38 0, L b. C COUNTY OF LOS ANGELES BUILDING AND SAFETY
Comp
BUILDING
Certified copy is hereby furni ed: FOR AAPLIC NT O-FILL ADDRESS
❑ Certified copy is filed with t county bu' ing ins c- BUILDING
tion department. ADDRESS
CITY. ZIP LOCALITY
Date App nt NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF.LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLO K I LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or-less.) TEL. � USE ZONE MAP
OWNER NO NO.
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 V CONDITIONS O
so as to become subject to the Workers' Compensation Laws. CIZIP U
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPEFIRE PROCESSED BY QY
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO.
CONST. ZONE O
Exemption, you should become subject to the Workers' p
Compensation provisions of the Labor Code, you must forth- ADDRESS NCO, a
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR I NO. Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE NO. SEWER MAP
(commencing wV
ction 7000)of Division 3 of the Business LIC.
and Professions nse is in full fort n�gf CITY ' - CLASS VALIDATION
(�'°r•!( SQ. FT. NO. OF NO. OF CHECK. BK. PG.License NumbeLic. ClassS�_ SIZE STORIES FAMILIES ONE
VALUATION D�
Conirac r Date DESCRIPTION OF WORV� NEW 1:1 G' ADD f ) —
❑ /
❑I am exempt under Sec. ,
�,. ALTER ❑
BAP.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL El
Signature APPLICA ) I No FINAL
OWNER-BUILDER DECLARATION (PRIrk / DATE ,.
I hereby affirm that I am exempt from the Contractor's License {M / -
Law for the following reason (Section 7031.5, Business and ADDRESS i 6 ci FINA
Professions Code): PRESENT BY
BUILDING a''•
❑ I; as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
:;.iE ;' 'iii, '
the structure is not intended or offered for sale(Section LOCALITY i 1� ::_. _ _
7044, Business and Professions Code.) MOVING TEL. . ► ! I ITEM`
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. 1 ,, ,
with licensed contractors to construct the project (Sec- 'I
ADDRESS } •EM_
tion 7044, Business and Professions Code.) _
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY 'SET BACK YARD HWY PROP. LINE WIDTH
hereby affirm that there is a construction lending agency for FRONT . ,��, r lit i
the performance of the work for which this permit is issued P.L. "
(Sec. 3097, Civ. C.). SIDE
P.L .
Lender's`Na e
9 LDMA Ref. #
P.C. Fee $ Permit Fee / :;n - ( �
Lender's dress .
a 1 certify at I have read.this application and state that the Issuance Fee LDMA P/C#
0 above' fo mation is torr I aog
ply with all County Investigation Fee
dordin nce and St a la s relading cons ucfio Total Fee LDMA Perm. #
and eA
hou e r p sen
of
is County o e er
2 upon th -me n. p pect' o
a
^ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant,or Agent Dat