HomeMy Public PortalAbout6034 AVON AVE_Building__ (5) WORKERS' COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) ..�'����
ora �S'� ,-' b .— COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nf Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING 3
ADDRESS
Certified copy is filed with the cou building inspec- BUILDING
tion department. ADDRESS ®3
Date G Applicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTI ROM WORKERS' NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. USE ONE MAP
I certify that in the performance of the work for which this OWNER NO. NO.
permit is issued, I shall not employ any person in any manner — SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS 0
Date Applicant CITY ZIP
U
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT G UP TYPE FIRE PR ESSED.BY Q
Exemption, you should become subject To the Workers' ENGINEER NO. �� CONST. ZONE I_/ Q �
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be / TEL. a'
deemed revoked. psO�G STATISTICAL CLASSIFICATION APT. ONDO. N
CONTRACTOR NOtT� z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �j NO. ��7
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions Code, and my license is in full force and effect. CIT CLASS BK PG VALIDATION
p, 4 SQ. FT. NO.OF NO. OF CHECK
License Number /w 9 Lic.Class SIZE STORIES FAMILIES ONE
y� ,tJ VALUATION
Contractor Gamey Date G $ DESCRIPTION OF WORK
NEW 1:1$ ADD ❑ $ enzro ,
I am exempt under Sec. ALTER ❑
B.BP.C. for this reason REPAIR ❑ $
Date: USE OF DEMOL
EXISTING BLDG. 17-1
Signature APPLICANT TEL. FINAL
NER-BUILDER DECLARATION PRINT NO. DATE G 2 7 2 0 4 A
I hereby affirm at I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL #.a a °. °.°
Professions Code): PRESENT BY
❑ BUILDING ! iO - 9675
I, as owner of the property, or my employees with ADDRESS =
wages as their sole compensation,will do the work and `q�� / o o.o
the structure is not intended or offered for sale(Section LOCALITY �w c! f 9 6 7 5
7044, Business and Professions Code). MOVING TEL.
1, as owner of the property, am exclusively contracting CONTRACTOR NO. 0 6, 0 9-8 7
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
YARD HWY
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. #
m Lender's Address P.C. Fee$ Permit Fee /,
I certify that I have read this application and state that the U
Issuance Fee SLDMA P/C#
o above information is correct. I agree to comply with all County Investigation fee C
0 ordinances and State laws relating to building construction, Total Fee V LDMA Perm. #
and hereb horize representatives of this County to enter
upo he v mentioned operty for inspection pur oses.
8-2 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date