HomeMy Public PortalAbout6037 AVON AVE_Building__ (5) a f WORKERS' COMPENSATION DECLARATION
f I hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T
insure, or a certificate of Workers' Compensation Insurance,
or ci certified copy thereof (Sec. 3800, Lob -) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.� 1Company y//rCa¢.
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS c�
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS 6032 /�
�-4AJ ,- ` .41
Date Gs a> Applicant CITY f t C ZIP LOCALITY
CERT FICATE OF EXEMPTI FRO WORKERS' NO.OF BLDGS. NEAREST
COMPENSATIO 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 ZONE 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 �Q 1 CONDITIONS 0.
CITY ZIP V
Date Applicant =
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL DISTRICT G UP TYPE FIRE PROC SED BY O
ENGINEER NO. CONST. ZONE V
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS W.
with comply with such provisions or this permit shall be d
�f T STATISTICAL CLASSIFICATION APT. C DO. to
deemed revoked.
CONTRACTOR "(�J O. � � � // z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.�c f DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O/(, % NO. /7,3 f_7 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC. Q
Professions Code, and my license is in full force and effect. CITY CLASS C �/ BK PG VALIDATION
�nf SQ. FT. NO. OF NO. OF CHECK
License Number ^3 7 Lic.Class SIZE STORIES FAMILIES ONE
y�� VALUATION
Contractor �c.R+�*�c3 Date DESCRIPTION OF WORK o� / NEW 1:1 $ 17 5r-
ADD ❑ ,
I am exempt under Sec. ALTER ❑
of
B.BP.C. for this reason — REPAIR ❑ $
DUSE OF
Date: DEMO'
EXISTING BLDG. ❑
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT NO. DAT -
I hereby affirm that I am exempt from the Contractor's License 7 2 0,3 A
Low for the following reason (Section 7031.5, Business and ADDRESS FI
Professions Code): PRESENTg # e e e•o 0 1
BUILDING "�
• 106..13
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 0 0.1 0 6,1 3;v
7044, Business and Professions Code). MOVING TEL.
1, as owner of theproperty, am exclusive) contracting CONTRACTOR NO.
Y 9 06 09 87
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TO7APROPALINE WIDTFROM H
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 . 3
Lender's Address _
3 I certify that I have read this application and state that the O S v
$ Y PP Issuance Fee LDMA P/C#
a above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee
R and ereb thorize representatives of this County to enter r LDMA Perm. q
up the bov -mentioned property for inspection purposes.
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� ( $ SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of Applicant or Agent Date