HomeMy Public PortalAbout5927 AVON AVE_Building_3/30/1989_stall tile RS' COMPENSATION DECLARATION,
her., y 'affirm that I hover certificate of consent to self A P m��C /� T��N F O R O � (���M�i�,(�" P E �n O V
insure, or a certificate of Workers' Compensation Insurance, (f� u� v Uv wu
or a certified copy thereof (Sec. 3800, Lab. C.)
,yCOUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No�O/.���� Company ,[
® Certified copy is hereby furnished. _ FOR APPLICANT TO FILL IN BUILDING "
fu� ADDRESS :� / :27
Certified copy is filed with the unty buildin inspec- BUILDING , l�
I ion departm�n).��,�)i �e ADDRESS G/ !� -•�
Date ( Applicant lLil7�`'C C.t�. 7 CITY ZIP 4— °.LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST ►l ,{(
COMPENSATION INSURANCE SIZE OF—LO-T--__ NOW ON LOT CROSS ST. f U L.c•
his section need not be completed if the permit is for one ASSESSOR
hu ed dollars ($100)or less.) TRACT BLOCK LOT NO. :MAP BOOK PAGE PARCEL
TEL. ��� USE ZONE MAP
I certify Iha the performance of the work for (which this
OWNER �j(J NO ` NO. Ea
permit is issued, not employ any person in any manner !ADDRESS L/CJ/(/ SPECIAL
so as to become subject orkers'Compens tion Laws. G���� CONDITIONS
Date Applicant CITY ZIP /
ARCH( R TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of r ENGINEER NO.
Exemption, you should become subject to the, Workers' CONST.r --
ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL.
/3 STATISTICAL CLASSIFICATION APT. CON
deemed revoked. L CONTRACTORNO• 2-1 DWELL. UNITS
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.
I hereby affirm that I am licensed under provisions of Chapter 9 " ADDRESS r( NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC p
Professions Code, and my license is in full force and effect. CITY � S' CLASS / BK PGVALIDATION a,
p� r- SO. FT. STORIES
NO.OF CHECK
License Number X / 9(f! Lic.Class ( SIZE STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK NEW
Contractor Date $ O
-� ADD
m exempt•under Sec. I ❑'
ALTER
B.BP.C. for this r _r REPAIR ❑ . $ N
USE OF DEMOL ❑,
EXISTING BLDG.
Signature j " APPLICANT , TEL. FINAL ,� �• n '
OWNER-BUILDER DECLARATION I PRINT) c NO DATE .P
I hereby affirm that I am exempt from the Contractor's License
Law following reason (Section,7031.5, Business and ADDRESS FI
Professions o PRESENTB �
❑ BUIL NG
I, as owner of the rt or my employees with AUAR
wages as their sole compenso will do the work and
the structure is not intended or offere le(Section «LOCALITY
7044, Business and Professions Code). I ` MOVING TEL.
I, as owner of the` ro ert am exclusivelycontractin CONTRACTOR
P P Y, sl•, ;
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). ,- ,--
i REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I her affirm that there is a construction lending agency for FRONT
the perfor ce of the work for which this permit is issued P.L.
(Sec. 3097, Civ. SIDE
P.L.
Lender's Name r r:
1 LDMA Ref. #
Lender's Address P.C. Fee$ Permit Fee
I certify that I have read this application and state that the Issuance Fee / 4✓° H LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee S
ordinances and State laws relating to building construction, f {
Total Fee J -S• LDMA Perm. #
and hereby authorize representatives of this County to enter _
upon th above-mentioned property for inspection purposes.
I
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date