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HomeMy Public PortalAbout6002 AVON AVE_Building_8/21/1991_fireplace repair WORKERS' COMPENSATION DECLARATION ~insure bora • irm acertif certificate have a s' Compensation at on Insurance, APPLICATION F O.R BUIL WA C` PERMIT or a certified copy thereof (Sec. 3800, Lab. C.),4 COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Policy No.1Lj�S�a�..Company-59r— BUILDING Company 5I ' ❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING PY Y ADDRESS JI[`�'c7ll Certified copy is filed with the county building inspec- BUILDING RC1 /��i r tion department. ADDRESS V© - /7 Date Applicant n le iT:��lLNjeiJ� CITY =i^-� (, ZIP /27 LOCALITY OF BLDGS' NEARESTIV 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 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 d CONDITIONS so as to become subject to the Workers'Compensation Laws. O CITY ZIP U Date Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If,.after making this Certificate of ENGINEER - NO DISTRICT GROUP TYPE FIRE PROCESSED BY CONST. ZONE O Exemption, you.should become 'subject to the Workers' w Compensation provisions of the Labor Code, you must forth- ADDRESS u� - 3 Gz.4Z eG� a with comply with such provisions or this permit shall be � T STATISTICAL CLASSIFICATION APT.. CONDO. Z deemed revoked. CONTRACTOR — �j7G^/�(.�/L7/'�syOti �j /f � _ LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.�DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9' ADDRESS NO. (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 BK PG VALIDATION S �� / SQ. FT. STO OF NO. OF CHECK License Number Lic. Class SIZE STORIES FAMILIES ONE q VALUATION �- Contractor � i1�Ka}e�•.(6J�r� tk h. DESCRIPTION OF WORK NEW ❑ $ J �--L-t�P El am exemp}.under Sec. 117 _ 7Z> r2E? ADD o ALTER 1101 B.&P.C. for this reason EPAIR� .$ Date: USE OF EXISTING BLDG. DEMOL Signature APPLICANT TEL. FINA /! OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License DATE Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By BUILDINGEl I, as owner of the property or my employees with ADDRESS _ wages as their sole compensation,.will do the work and. LOCALITY , �W the structure is not intended or offered for sale(Section 7044, Business and Professions Code.) MOVING TEL. ' ";L ❑ I, as owner of the property,'am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- + a i-- ADDRESS i tion 7044, Business and Professions Code.) _.€, ij^t^v• :^t REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT ' ('k R the performance of the work for which this permit is issued 'P.L. (Sec. 3097, Civ. C.)� /y SIDE /"V /i-/ P.L. _ _ Lender's Name. 0;i i_;- - $ —� ^� LDMA Ref. # P.C. Fee$ Permit Fee 2 -- 3 Lender's Address 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 0 ordinances and State laws relating to building construction, Total Fee Aq • a� LDMA Perm. # a and hereby authorize representatives of this County to enter 22=ed property for.inspection urp es.e P �( SEE REVERSE FOR EXPLANATORY LANGUAGE Applicant or Agent Date - i