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HomeMy Public PortalAbout5927 AVON AVE_Building_8/7/1991_earthquake damage replacement • r yea WORKERS` COMPENSATION DECLARATION nn —01 nD insure boraffirm certif cer tificate of Workerscertificate Compensatioonsensuro ncef O 'N FO ®� �'�U V LI or-we t y er °�(Sec. 3800,.Lab. C.) .�ytL f LC �/S` '!Qc6KC%'4 ,/j COUWT`Y'Cr;,lO ANGELES BUILDING.AND SAFETY .Policy No. Company '06- t fol/-i C o ElBUILDING Certified copy is hereby furnished. FOR R APPLICANT TO FILL IN �, ADDRESS fJ BUILDING' Certified copy is filed with'the county building inspec- ADDRESS �'�/ lJ e '. tion-department. - 7 IV,)—I ( CITY' 2 f 1 `�� ZIP 9. 7 /.S� LOCALITY Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPT16N 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" BLOCK LOT MAP BOOK : 76 PAGE PARCEL hundred dollars:($100) or less.), TEL. USE'ZONE MAP OWNER O' C C. 0►` fl�/ NO. NO. I certify that in the performance of the work for which this oSPECIAL } permit is issued, I shall,not employ any person in any manner _ ADDRESSOta 't. CONDITIONS t1. so as to become subject to the Workers•'Compensation Laws. O CITY Qi(-t C �. ZIP Date Applicant, ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If;.after.makingthis Certificate of. ENGINEER NO. , CONST. ZONE Exemption, you.should become subject to.the •Workers' " U Compensation provisions of the Labor Code; you must forth- ADDRESS with 'comply with such provisions. or.,this permit shall be 2 STATISTICAL CLASSIFICATION APT. CONDO. N .deemed revoked. CONTRACTOR �,9(f.Slf'tACI)at'NOs��"7✓�2 Z_ LICENSED CONTRACTORS DECLARATIONJ LIC.- CLASS NO. a� DWELL. UNITS I hereby affirm that.I am licensed under provisions of Chapter 9 ADDRESS I A f=_ W «�<r' NO. SEWER MAP (commencing with Section 7000)of Division'3,of the Business LIC.' and Professions Code,and my license is in full force and effect: CITY rcelbCLASS BK. PG. VALIDATION Q' /7 SQ FT.- NO. OF NO. OF CHECK,- Licen'se Number Lic. Class SIZE STORIES IFAMILIES ONE VALUATION Contractor L. �r f> IJ Date- g / t DESCRIPTION OF WORK NEW ❑ $ Q Q©® p J El am exempt under Sec. ✓` L ,AI a ('L ''/ 14 ADD ❑ D /� j,. ALTER ❑ •- - B.BP.C. for this reason r441�F 3}Z� -� 4- � REPAIR ❑ $ Date: USE OF EXISTING BLDG. ` DEMOC:_J Signature APPLICANT TEL. FINAL OWNER=BUILDER DECLARATION. (PRINT)' NO. DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL'. Professions Code): PRESENT _. BY - BUILDING f' ❑ I, as owner of the property 'or'my employees with ADDRESS _ 6.. t..,i !•,=_- wages as their sole compensation,will do the'work and ' the structure isnot intended or offered for sale(Section LOCALITY _ s a:•'.. •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 `•;i I! _.. -_s,� 0 tion 7044, Business and Professions Code.) REQUIRE- CONSTRUCTION LENDING AGENCY SET BACD YARD HWY TOTAPREOTBACNEFROM WI TH `s—• '• - • - I hereby affirm that there is a construction lending agency for FRONT ;-. t R the performance of the work for which this permit is issued P.L. .�s?i?'"�-• _=)=' (Sec. 3097; Civ. C.). SIDE., Lender's Name, - LDMA Ref. # P.C. Fee$ Permit Fee omaryry /� • ��/ _ Lender's Address o j certify that I have read this application and state that the Issuance Fee ✓' � LDMA P/C# D above information is correct. I agree to comply with all County Investigation-Fee. Q 8 ordinances and State laws relating to building construction, Total Fee .4-40 ' LDMA Perm. # a and hereby authorize representatives of this County-to enter upon the ab e-mentio a property for inspection purposes. } SEE REVERSE FOR EXPLANATORY LANGUAGE Jignature.of Applicant or Agent Date