HomeMy Public PortalAbout6145 AVON AVE_Building__ (2) a WORKERS C6MPENSATION DECLARATION T w � R-
YnHereby affirm that I have a certificate of consent to self - - - APPLICATI1 N- FOR BUILDING PERMIT �
insure or a certificate of Workers Compensation Insurance r
or a`certified copy thereof (Sec 3800 Lab C ) - t a 4
COUNTY OF LOS ANGELES I BUILDING AND SAFETY )
Policy No Company ,.
❑ . Certified copy is hereby furnished FOR APPLICANT TO FILL IN ^BUILDING
ADDRESS s
❑ Certified copy is filed with the county building inspec BUILDING I,/ --- - 1
do de artment ADDRESS v
Dater ra '-'Applicant M /�h.j/j/`
CITY �L� G ZIP �-
_ LOCALITY
` FX
CE IFICATE OF EXEMPTION FROM WORKERS - O OF BLDG - - — o NEAREST _
I COMPENSATION INSURANCE SIZE OF LOT,j j NOW ON LOT CROSS ST "
(This section need not be completed if thelpermit is for one �. ASSESSOR V
hundred dollars ($100)or less ) TRACT BLOCK LOT NO" C;ks MAP BOOK PAGE PARCEL >
TEL (;
I certify that in'the performance of the work for which this OWNER �Q USE/Z�J NE MAP t
permit is issued I shall not employ any person in any manner c 7� II - r/�!/ SPECIAL O
so as to become subject to the Workers Compensation Laws ADDRESS eq J 73000 " CONDITIONS , _ u
Date' Applicant - CITY _- _ ZIP _ fi {
NOTICE TO APPLICANT"If after making this Certificate of ARCHITECT OR TEL DISTRICT GROUP TYPE _ FIRE _PR C ED BY O
T Z NE
Exemption you should become subject to the Workers - ENGINEER NO CONS0 y /
Compensation provisions of the Labor Code you mustIforth ADDRESS Y L
with comply with such provisions or this permit shall be _ __
deemed revoked' TEL STATISTICAL CLASSIFICATION APT NDO Z
' Y ' CONTRACTOR NO n _
t LICENSED CONTRACTORS DECLARATION - __ - - LIC _ _ _ CLASS NO 9 - t 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 and _ - LIC _ SEWER MAP
Professions Code and my license ism full force and effect CITY CLASS - VALIDATION -
` BK PG_ ♦` y
SO FT NO OF r NO OF CHECK
4 i; ; 1 ` ' SIZE' STORIES - r - FAMILIES 'ONE
License Number Lic Class
�3 3 4 , VALUATION _
.r a r i
S I 'I e,A t t c't+t ti , DESCRIPTION OF WORK �Q� NEW -❑
Contractor Date❑ ❑
�a I am exempt under Sec - — I -
/ ADD s
_ ALTER Q�
B&P C for this reason _ C)C.D r AREPAIR ❑ $
Da USE OF t 243Q2A
EXISTING BLDG mi O-C. /) e, DEMOL
Signature . 'r t APPLICANT l D TtE -�� FINAL r # s o • o •
OWNER BUILDER DECLARATION PRINT
I hereby affirm that I am exempt from the Contractor s License ;C yl� DATE "0 06 63
J�7 Law for the following reason (Section 7031 5 Business and ADDRESS � FIo e b �63=Professions Code) Y PRES NT - — - ' r- m:BUILDING 327-86I as owner of the property or my employees with ADDRESS r-wagesastheirsolecompensation will do the work and the structure is not intended or offered for sale(Section LOCALITY s-70"-'Businessrand Professions Code) - MOVING - � - — - T❑ CONTRACTOR N1,4
I as owner of the property"am exclusively contracting with licensed contractors to construct the project (Secrtion 7044 Business and Professions Code) ADDRESS -' CONSTRUCTION LENDING AGENCY - - REQUIRED -YARD -HWY TOTAL SETBACa r , r-aeSET BACK PROP LIWIDTH r _
I hereby affirm that there is a construction lending agency for FRONT - y a " t
the performance of the work for which this permit is issued — - P L _ _ t
(Sec 3097 Civ C ) SIDE t ''_ J' t
.. _ _ �... _P L
vLender s Name "
$ P C Fee$ - Permit Fees' — L !3 1 LDMA Ref #
Lender s Address _ qq'� ^^ tom ,
I certify that I have read this application and state that the _ _ _ Issuance Fee �d LJ--- - -LDMA P/C#
above information is correct I agree to comply with all County Investigation Fee _ *rt T 4 t
ordinances and State jaws relating to building construction - Total Fee- O�
v and hereby authorize representatives of this County to enter - LDMA Perm #
up he above me o e erty f r inspects n pur oses a y
/� j jl fi�/S/ SEE REVERSE FOR EXPLANATORY LANGUAGE 1 e s
Signature of Applicant or Agent-ddd w J
9 PPO
�\ r