HomeMy Public PortalAbout5933 AVON AVE_Building_1/30/1990_reroof WORKERS' COMPENSATION DECLARATION
insure,oraafcertif to lf APPLICATION FOR BUILDING PERMIT
or 9 certified copy thereof (Sec. 3800, Lab, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
El Certified copy is filed with the county building inspec- ADDRESS ILDIN
tion department.
Date r r Applicant .. . ..F CITY ZIP LOCALITY
Pp NO. OF BLDGS. 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 is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.)
OWNER TEL TEL.NO. USE ZONE MAP
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL
CONDITIONS
so as to become subject to the Workers' Compensation Laws. >_
CITY ZIP CL
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE J
Exemption, you should become subject to the Workers' LL
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO.
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP d
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION H
> r SQ. FT. NO. OF NO. OF CHECK
License Number ' Lic. Class.r SIZE I STORIES FAMILIES ONE
VALUATION
Contractor %r r� Date DESCRIPTION OF WORK NEW ❑ }
ADD El ;
El ,f! .. ►
I am exempt under Sec. ALTER ❑
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
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
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ,
the structure is not intended or offered for sale(Section LOCALITY
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 Professions Code.)
CONSTRUCTION LENDING AGENCY SETBACKYARD Hwv TOTaPROPACNEFROM WIDTH
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
LDMA Ref. #
P.C. Fee$ Permit Fee
Lender's Address I ,
a 1 certify that I have read this application and state that the Issuance Fee LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
8 ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date