HomeMy Public PortalAbout5937 AVON AVE_Building_6/11/1992_patio addition WORKERS' COMPENSATION DECLARATION I t
I hereby affirm that I have a certificate'of consent to self M C 1N p U d L D d H F E[ �ULn d U
insure, or a certificate of Workers,Compensation Insurance, L/�1LI LI !!1� LI V /U
or a certified copy thereof (Sec. 3800, L b. C.) t•
- - COUNTY-OF LOS ANGELES• •• BUILDING AWD SAFETY
h`J-7.3 . ' 1' Y;`
Policy N,14 Company
BUILDING
I� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ Certified-copy is filed with.the county building inspec BUILDING
Tion•department. ADDRESS ��yy
' '�• C'/.�►- ZIP
CITY' LOCALITY
Date `�' — pplican `^�`�""
NO. OF 86DGS. 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 s'for one TRACT' BLOCK. LOT NO. "' ASSESS OK' ' PAGE PARCEL
hundred.dollars ($100)or less.). � / TEL.
OWNE I9G 14 _ NO.- USE ZONE MAP "
I certify that in the performance of the work for which this NO.-
permit;is issued, I shall not.employ any•person in any.manner ADDRESS �!D /� SPECIAL 0-
CONDITIONS,
so 6s to become subject to,the.Workers,Compensation Laws. /� O
CITY G / ZIP - U
Date Applicant, - ARCHITECT OR _ TEL.'
NOTICE,TO APPLICANT:, If, after making:this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY
CONST. ZONE O
Exemption,, you should, become subject to the.Workers` / w
Compensation provisions of The Labor Code; you must forth- ADDRESS �� f/ LG,� Q - a
with comply with such:provisions or this permit shall be `TEL. STATISTICAL CLASSIFICATIO / APT. CONDO. v7
deemed revoked CONTRACTOR J /
o C°f7..o✓ s" � Z
LICENSED CONTRACTORS DECLARATION 11C: C' CLASS NO.Q __D EL�UNITS'
I hereby affirm that I am licensed under provisions of Chaptec9 ADDRESS
'(commencing with Section7000)of Division 3 of the Business LIC. SEWER MAP
and Professions Code,.and_my license is infull:force;and effect. CITY_ _ - Lo CLASS- BK VALIDATION
SQ. FT. NO. OF - NO. OF CHECK
License Number Lic. Class SIZE STORIES FAMILIES "'ONE'
DESCRIPTION OF WORK NEW t�ALU;POI :B�
Contractor_ /�J//4fa.7' Date {T ' ��,-
ADD ❑ D
am exempt under'Sec. - ALTER ❑
B.&P.C. fof,this reason
Date: USE.OF. RE IR
PA ❑ §
EXISTING BLDG. DEWL
r ; APPLICANT TEL.
Signature .. Lyle fiC -(j. FINAL
OWNER-BUILDER DECLARATION (PRINT) �O _ 6 �J
I hereby.affirm that I am exempt from the Contractor's License -7—
Law
DATE l v
Law for the following real n:,(Sectio,n.7031:5, Business:,and ADDRESS 'Z FINAL .�-',:. F r .-.7%
Professions'Code): PRESENT. By
/' Lti _.:
❑ I, as owner of theproperty, or'm 'em to ees with BUILDING :^s r t
, Y P Y. ADDRESS
wages as their sole compensation,will do the work and
LOCALITY �.r.
the structure is not intended or offered for sale(Section: D. :1 ;+ ..
7044, Business and Professions Code.) MOVING.:. TEL.
I,as owner of the.property, am exclusively.contracting ,
CONTRACTOR NO.
with licensed contractors to.'construct the project (Sec-
ADDRESS.
tion 7044, Business and Ptofessions Code.)
REQUIRED TOTAL SETBACK FROM EXIST: .
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
v
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 ,
P.L.
Lender's Name, ;{h
'. ym
/, _ LDMA Ref. #
P.C. Fee$ , Permit Fee
pp t
Lender's Address L� 70 d -f ,1
1 certify that I have read this application and state that the Issuance Fee /' / , LDMA P/C# D j ; '<�
o .. . 'i..„ r7
8 above information is correct:I agree to:comply with all County Investigation Fees' _-
/��..� b ;,..
R ordinances and State laws relating to.building construction, Total Fee LDMA Perm. # tet✓' .L;`!„_•':
a and hereby authorize representatives of this County,to enter
upon the abdve-mentioned property..for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signafure of Applicant or Agent Date' s