HomeMy Public PortalAbout5930 AVON AVE_Building_3/30/1992_workshop to guest house -WORKERS'.COMPENSATION DECLARATION
I hereby affirm that F have Workers'
a.of consent 6self A LI p��OM�O LI V F O 1 O M d D M H� p E E D U
insure, or a certificate of orr kers' Compensation Insurance, = _. ,
or a certified copy thereof'(Sec: 3800, Lab. C.). COUNTY OF LOS'ANGELES' BUILDING AND SAFETY
Policy No. Company `
' BUILDING
❑ Certified copy is here by.furnished.. > FOR APPLICANT.TO FILL IN ADDRESS. C G �
❑ Certified copy is filed with the county buil"ding inspec- BUILDING t-,? �
tion department. ADDRESS.7 7th eq. e�
CITY' '7!J U'r� ZIP g/ '/. LOCALITY
Date Applicant NO. OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF. LOT.-+( h NOW ON LOT NEAREST
CROSS ST.
COMPENSATION INSURANCE-
ASSESSORj�P3�-�'j LOT N062,(""
.(This section need not be completed:if'the,permit.is for one TRACT r BLOCK . MAP BOOKfic PAGE /� PARCEI��
hundred dollars ($100)or,less:) y TEL.
., OWNE E�/� ��� USE ZONE MAP
I certify that;in the performance of the'wis ork for which this (/
INC.
SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS-���1 c/4-(0i*1 eW4e /�.! CONDITIONS O
so as to become subject to the:Workers_Compensation'Laws. . U
ZIP'"< 1!y 2S
Date•- Applicant ARCHITECT OR TEL. S
NOTICE TO APFLICANT:. If, ,after making,this,.Certificate of ENGINEER NO DISTRICT GROUP TYPE' FIRE PROCESSED BY Q
CONST. Z�IE U
Exemption; you 'should- become subject to the Workers' r/ ;/{ w
Compensation provisions of the Labor Code
must forth- ADDRESS �I •�' a
with comply with such provisions or this permit•,shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR Q f NO.' 7-
TORS-DECLARATION LIC. CLASS'NO. DWELL.-UNITS
I hereby affirm that I am licensed under.p'rovisions of Chapter 9 - ADDRESS NO.
(commencing with.Section 7000)of Division'.3 of the Business LIC. SEWER MAP
Fond ProfessionaCode,and my license is,in full force and effect. CITY CLASS BK PG.& Y VALIDATION '
SQ.FT NO. OF NO. OF CHECK
License.Number Lic. Class SIZ STORIES FAMILIES ONE '
❑ VALUATION
Contractor Date DESCRIPTION OF WORK NEW
❑I am exempt under Ser. ADD ❑ /
��--- ALTER D
B._BP.C. for this.reason 4ZS REPAIR ❑ S
Date: USE,OF
EXISTING:BLDG J DEMOL ❑
Signature APPLICANT TEL.
I hereby affirm that 1 am ekempt,from the Contractor's License DATE �^',�•., '
ADDRES S /,Y, /TVA 7 '
Law for.the following reason (Section 7031.5, Business•and FINAL _
Prroofes�sions Code): PRESENT By
LJ� 2AA�
I, as owner of The property,-or my employees with ADDRESMINS/� ' tv
wages as their•sole com ensation,will do the work and /� n117,1'7 't
thestructure is not intended or offered for sale-(Section LOCALIT��(Q A►JR'1 �y�
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
tionJ044, Business and Professions Code.)
REQUIRED
TOTAL SETBACK FROM EXIST.;
f \
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH S { S 1 '' -vi
I hereby.affirm that there is a constructionlending agency for FRONT
the performance of.the-work for which this permit is,issued P.L. — —A
(Sec: 3097, Civ. C.). SIDE '-'•i µ s_ _ _
P.L.
Lender's Name.
m �'� LDMA Ref. # r G I€,i
- -
P.C. Fee$. Permit..Fee . - _ ...,
Lender's Address
a I,certify that I'have.read this application and state that the Issuance Fee :57 LDMA P/C#
8 above information.is correct. I agree-to comply with all'County Investigation Fee' �7
r _ ordinances and State.laws relaying to building construction, - Total Fee .4 49 LDMA Perm.'#
4=or
esentatives.of this Count to enter
D.
pr erty for inspection purposes. -
Q
d SEE REVERSE FOR EXPLANATORY LANGUAGE „
Agent Date