HomeMy Public PortalAbout6028 AVON AVE_Building_6/9/1987_reroof ,10 WORKERS COMPENSATION DECLARATION
-Gherel6i affirm that I have ertiftcate of consent''to self I CATION
FOR
BUILDING.
UBL®ING. PERM!T
insure or a certificate of Workers Compensation-Insurance r\
APPL
or a certified copy thereof (Sec 3800 L b ) 1 t
t - _ COUNTY,OF LOS ANGELES BUILDING'AND SAFETY 1`
Politcy NoG�O_�� Company - �'
f q
0,1, BUILDING
Certified copy,is hereby,'furnished r y FOR APPLICANT TO FILL INus ADDRESS �o t
Certified copyis filed with the co'unjX building inspec BUILDING
f (tion"department 'r ADDRESS'
+� r J!
Date $ Applicant k, CITY ^' * ZIP V LOCALITY
CERTIFICATE OF EXEMPTIO ROM WORKERS d r NO OF BLDGS NEAREST s' 4
I SIZE OF LOT v NOW ON LOT r" V CROSS ST
a - COMPENSATION INSURANCE , ,
` (This section need notrbe completed if,the permit is for one, M z ASSESSOR N"
{ " hundred dollars ($100)or less ) 4, +TRACT BLOCK LOT NO t - MAP BOOK PAGE PARCEL"
r +.$-TEL ��''.._ r USE NE MAP
a I certify that`'in the performance�of,the work for which this OWNER NO NOr
permit is issued I shall not employ any person in any manner rte' SPECIAL k, +
so as,to become subject to the Workers Compensation Laws- ADDRESS CONDITIONS
CITY_ 't - � ' ZIP �
.Date Applrcan ARCHITECT OR. TEL r #
y NOTICE TO APPLICANT If after making this Certificate`of # '+` _ DISTRICT GROUP TYPE r FIRE PR ESSED BY
s ENGINEER 6' - NO t �d
+`
Exemption you�sFiould become subject to the Workers ,� CONST ZO F-
Compensation provisions of the Labor Code you must forth ADDRESS
" with comply�,wrth such provisions`orthis permit shall be
deemed revoked __ TEL STATISTICAL CLASSIFICATION -APT ONDO (q ,
AI CONTRACTOR+, a NO e e l 4 n '
LICENSED CONTRACTORS DECLARATION , LIC CLASS NO DWELL'UNITS 4 Z
�
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 4e,/,6 J I NO 7 t
(c'ommenarig with SechonJODO)of Division on 3 of the Business and SEWER MAP
>
Professions Codec and my license is in full force and effect, CITY ' S CLASS ,C y r VALIDATION
SQ FT NO OF NO`OF CHECK BK PG
License Number / ( �L°ic Class eM'- -"' SIZE - - _ STORIES - FAMILIES'" -+ --ONE
/A� � //�jO O _ _r a� VALUATION 4
ContraclOrUIJ IQ/[.I_��1 9L�'= Date°' O'` , DESCRIPTION OFWORK _ p2�, NEW +O S66
-
- . ADDa �,
r
['am exempt under Sec s r O ' 4
t,� It - ALTER
B'&P C for this reason s� 4�107 _ REPAIR f
Date _P USE OF �
EXISTING BLDG c� DEMOL Q
Signature - a APPLICANT +-,' - TEL FINAL
OWNER-BUILDER DECLARATION '
(PRINT), NO DATE 2 '
I hereby affirm that I am exempt from the Contractor s License r 4 Q °
'Law for the following reason (Section 7031 5 Business and- ADDRESS FIN
` "' i
pProfes'slons Code)" v +srf-4 _ U 1 S _ By f
+ ` r BUILDING
j as owner of the property or my employees with ADDRESS �,7 2 Q 5 A
- wages as their sole compensation will do the work and - LOCALITY, - + jr- `
the structure Is not intended or offered for sale(Section —` �� / # o • o'• o'J,
s 7044 Business and Professions Cod`e)1 rrr p MOVING s, : TEL a C� G /7 -
1?`as owner of the property am exclusively contracting CONTRACTOR- NO i ,( 't1 11 5.5 0
with licensed contractors to construct the project (Sec-
' a - ADDRESS va ^+ = w
Jion 7044 Business and Professions Code) - (• 0 1 1 S5 0 0
aREQUIRED YARD HWY TOTAL SETBACK
CONSTRUCTION LENDING AGENCY , , SET BACK PROP LINE WIDTH `+t 06 09-87 '
°
I hereby affirm that there is a construction lending agency for FRONT ti -`. -
' x the performance of the work for which this permit is issued P'L a r
a (Sec 3097, Civ_C ) g - .` SIDE a
Lenders NameAA
a LDMA Ref'#' ,, t
Lender s Address ^ P C Fee$ Permit Fee w i
} +' i y Yr, ® P ,y • f L, 1
I�certify that I have read This application and state that the �' `, " Issuance Fee LDMAIP/C M '
a -above information is correct I agree to comply with all County r Investigation Fee
ordinances and State laws relating to building construction t . Total Fee -b, LDMA Perm
and hereb thonze representatives of this County to enter -
upo th a ov mentioned property for'inspection purposes
a e 13
-�l �{ SEE REVERSE FOR EXPLANATORY LANGUAGE t
Signature of Applicant or Agent 9 ate