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HomeMy Public PortalAbout5930 AVON AVE_Building_12/19/1991_reroof WORKERS' COMPENSATION DECLARATION I hereby affirm that I havecertificate of consent to self •� (� (�M. �: p �' insure, or a certificate of Workers'. Mkers' Compensation Insurance, U. jJV(J�/u or a certified copy thereof (Seca 3800, Lab COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Na. --;�ompany BUILDING / ❑ Certified co is hereby s� FOR APPLICANT TO FILL IN 6f1 r�-��y� PY Y - !-/ �-dL� ADDRESS copy is filed with the-department.. co y building ins BUILDING ;/• „ / tion ADDRE Dat SS (O �l/ �Q CITY' ZIP LOCALITY e Applicant NO. OF BLDGS. CERTIFICATE OF EXEMPTION RONi`WORK S" SIZE OF LOT NOW ON LOT NEAREST CROSS ST. COMPENSATION INSURANCE - • ASSESSOR (This'section need not be completed if'the permit is for one TRACT BLOCK LOT NO.. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. OWNER 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 SPECIAL a CONDITIONS so as to become,subject.to the Workers Compensation'Laws. • - O CITY r ZIP V Date Applicant ARCHITE OR TEL. ae NOTICE TO APPLICANT: If, after Makin this Certificate of - ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY O Exemption, you'should become subject' to.the Workers' ` CONST. �NE w Compensation provisions of the Labor Code, you must forth- ADDRESS' _ 444 �� J G��eg� N with comply with such provisions or,this permit;shall be 4TEL .� STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR I� NO.. _ LICENSED CONTRACTORS'DECLARATION LIC. CLASS DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS',65-2 3 "� ' NO. c 4T (commencing with Section 7000)of Division 3 of'the Business LIC. � SEWER-MAP and Professions Code;and my license is in full force and effect. CITY_ CLASS VALIDATION BK.. PG. ' SQ..FT. NO.-OF. NO. OF - CH E K - _ - License Number.� Q � Lic,Class SIZE. STORIES FAMILIES ONE �( Lp / DESCRIPTION-OF WORK: NEW ❑ VALUATION Contractor, „ Date $ �t►s/1 _ ADD ❑. / D ❑I am exempt under Sec. c �S ALTER .❑ BAP.C. for this reason REPAIR ❑ $- 1011) Da USE OF, EXISTING BLDG. DEMOL ❑ APPLICANT- FINAL Signature L OWNER-BUILDER DECLARATION PRINT ( ) l0 /C O� � DATE ;�i�../✓/ 2 I hereby affir that'I am exempt from the Contractors License Law for the following reason (Secfion 7031.5; Business and , ADDRESS �/J+!v/ EJB �`�7 lFINAL• - - Professions Code): PRESENT By,.: BUILDING ❑ I, as owner`of the property,.or my employees with . - ADDRESS ;1 wages as their sole compensation;.will do the work andthe structure is not intended or offered for sale(Section LOCALITY _ 7044, Business'and Professions Code.) " • MOVING TEL. ? EIa ❑ CONTRACTOR NO. _ ,; I,,as owner of the property, am exclusively contracting s;-,t y� 1 -' with licensed.contractors to.conWuct.the project.(Sec- ADDRESS' tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM. EXIST. CONSTRUCTION LENDING AGENCY.. SET BACK. YARD _ HWY PROP. LINE WIDTH. } r I hereby affirm that there is a construction lending agency for FRONTthe performance of the work for which this permit•is issued P.L. (Sec. 3097, Civ. C.). :SIDE P:L: f Lender's Name // LDMA Ref. # P.C. Fee:$ Permit Fee Lender's Address 1 certify that I"h6ve read this application and'state that the Issuance Fee 7� CDMA P/C# ! above infor tion is correct. I agree to comply with all County Investigation Fee 8 - ordinance a d State laws relati o building construction, Total Fee �`©. O / LDMA Perm. # I a and her y uthohze repres at' of this County to enter upon a ove tion pro fot,inspection purposes. SEE-REVERSE FOR EXPLANATORY LANGUAGE. Signature of epplicant or Agent Date. -