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HomeMy Public PortalAbout6003 AVON AVE_Building_6/17/1991_reroof WORKERS' COMPENSATION DECLARATION t ins�`e bor a certif cane of Workers'' Comtpensation Insof urancef O LI V F o R O M 0 d D m CG p CE QGU E or ❑ certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF.L•OS ANGELES BUILDING'AND SAFETY Policy,!k- Company BUILDING ❑' Certified copy.is.hereb,•y furnished. FOR APPLICANT TO FILL IN ADDRESS v Q, Certified copy is filed with-the county building i c- BUILDING A tion'department. ADDRESS / (/ CITY �( �' ZIP LOCALITY Dateplicant _ NO. OF BLDGS. CERTIFICATE OF EXEMPT N fROM WOR ERS' SIZE OF LOT NOW ON LOT NEAREST CROSS T. COMPENSATION INSURANCE S 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.) A, /� TEL. USE ZONE MAP NO. I certify-that in the performance of the.work for which this SPECIAL. _ - } C is issued, I shall not employ any person in any manner ADDRESS CONDITIONS 4 so as-to become subject,to the Workers' Compensation Laws. / O CITY '^ "'ZIP U .Date Applicant, ARCHI CT OR TEL. NOTICE TO-.APPLICANT: If, after,making this Certificate of ENGINEER NO. DISTRICT GROUP. TYPE FIRE PROCESSED BY 9 CONST. ZONE Exemption, you•should. become. subject to the,Workers' �D p Z / a Com ensation provisions of the Labor Code, you must forth-' ADDRESS O J V with comply with such.,p*rovisions or this permit shall .be TEL r STATISTICAL CLASSIFICATION APT. [CONDO. Z deemed revoked. CONTRACTOR NO, _ LICENSED CONTRACTORS DECLARATIONCLASS NO.�DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 49-,-T/� W O. (commencing with Section 7000)of Division 3 of the Business / �/ Q LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION Q SQ. FT: NO. OF NO. OF CHECK License Number S 3 3z_ Lic. Class g SIZE*, STORIES FAMILIES ONE // VALLION Contractor ate '' / DESCRIPTION OF WORK+ P. NEW ❑ $ ®®©'70 ❑I am exempt under Sec. ADD ❑ D.. - ALTER ❑ - ; z B.&P.C. for this reasonREPAIR ❑ $ Date: USE OF i L EXISTING'BLDG. DEMOL ❑ _ Signature APPLICANT TEL. FINAL CJ y i j t'�` NER-BUILDER DECLA ATION (PRINT). NO. DATE It� I hereby affirm that I am exempt from.the Contractor's.License ! `5 ' Law,for the'following_reason (Section 7031.5, Business and ADDRESS e FINAL i 11J.AL 6 38 Professions Code): PRESENT By � 4. L"L } _" BUILDING si El 1, as owner of the-property, or'my employees with ADDRESS' " _ wages as their sole compensation;wilIdo the work and elf f1t o i, the structure is not intended or offered forsale(Section LOCALITY 7044; Business and Professions Code.)' • MOVING .TEL. ' ❑ 1, as owner of the property, am exclusively contractin CONTRACTOR NO. with licensed contractors to-construct the project (Sec -'' #- E�-1i .w ADDRESS' tion 7044, Business and Professions Code.) L- sy :jai REQUIRED CONSTRUCTION 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 the performance of the work for which this:permit_is issued. P.L. ` (Sec. 3097, CIV. C.):: :'SIDE.:, P.L., Lender's Name p p LDMA Ref. # Lender's Address' P.it. Fee$ Permit Fee • O 0 a o I certify that I have read this application and state that the Issuance Fee LDMA P;C# 0 8 _ above information is correct..)agree to comply with all County Investigation Fee 0 ordinances and State la,:vs relating 1 building construction, Total Fee _LDMA Perm. # Q. and her authorize represent of this County to enter " upon a bove;m ti ed pe for inspect" purposes. a 04 ��' c SEE REVERSE FOR EXPLANATORY LANGUAGE 25—�Signature of Appli ant or Agent Dat