HomeMy Public PortalAbout6267 AVON AVE_Building_4/4/1989_bathroom interior revision and remodel � " t WORKERS' COMPENSATION DECLARATION
"`1 "ereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT
or a certified c��y thereof (Sec. 3800, LaI4. C.) COUNTY OF LOS ANGELES BUILDING AND SAFE
or y NoQ a �Compony e
BUILDING
" Certified copy i ereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ ie sled with the county by l ing inspec- BUILDING / 7�- /1 v
art ADDRESS 6 �j
Date pii$fin / �/ CITY +� CA ZIP LOCALITY
l� NO. OF BLDGS. /) NEAREST
CE TIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCEASSESSOR
(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.) n',y TEL.. �
( USE ONE MAP
I certify that in the performance of the work for which this SPE }
permit is issued, I shall not employ an person in an manner ADDRESS 3 0 GN Q t GO?"1� SPECIAL O
P P Y Y P Y CONDITIONS
so as to become subject to the Workers'Compensation Laws. yam, ,�� U
CITY SA-IJ NA -!mb zip
Date Applicant ARCHITECT OR TEL. 0
ENGINEER' DISTRICT. GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of NO. CON NE
Exemption, you should become subject to the Workers' C/1e 1#7 w
Compensation provisions of the Labor Code, you must forth- ADDRESS J��IIJJ ---���iFFF��� 0-
with comply with such provisions or this permit shall be ,j((pA TEL STATISTICAL CLASS A ION APT. CONDO. N
deemed revoked. CONTRACTOR r `1( NO. ql 7 3 �o Z
LIC. S NO. DWELL. UNIT
LICENSED CONTRACTORS DECLARATION 7(� ��(}�r(j FF NO. ����j�
CLASS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS
(commencing with Section 7000)of Division 3 of the Business !n /n� LIC. SEWER MAP
l�Y ��
and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION
tt I SQ. FT. NO. OF N0-0 F CHECK
License Number 13 943 3 Lic: Classes SIZE STORIES FAMILIES ONE
/ J( `'_ r /� VALUATION
Contractor AtE• �I�NuLC4 Date _7' DESCRIPTION, OF WORK ��1 I I�► 1 1 dT�.. EW ❑ s-7
El I am exempt under Sec. T`Cao U M 1�e.V l��� IJADD LJ CJ V CJ ►
-` a,�,� ALTER
B.&P.C. for This reason
I` 01644 on e REPAIR ❑ $
~f a
USE OF DEMOL ❑
Date: ai ? ?s-
EXISTING BLDG. "" -_ -
APPLICANT TEL. G i •I
Signature (PRINT)A 1�• J(Cr NO. 7��7(� FINAL v
OWNER-BUILDER DECLARATION / r� I` ` DATE 'T'i f=.(
I hereby affirm that I am exempt from the Contractor's License b W �� �r ( �,(� 'r,'y- a •,..°
ADDRESS
Law for the following reason (Section 7031.5, Business and FIN ,. i• Er•� _ -�
Professions Code): PRESENT. By �`" `f
❑ 1BUILDING `
.1Ai:,a"ey_^
I, as owner of the property, or my employees with ADDRESS 't: '-7L
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code. MOVING TEL.
❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO. } 1F 1_r-_'t_6+1; fir' Ti,
with licensed contractors to construct the project (Sec- _-1 r _ a R',
tion 7044, Business and Professions Code.) ADDRESS " Art .c l
REQUIRED TOTAL 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
m LDMA Ref. #
P.C. Fee$ Permit Fee
Lender's Address s n: :
o • LDMA P,/C
0 1 certify that I have read this application and state that the Issuance Fe
above information is correct. I agree to comply with all County Investigation Fee + ,
0 ordinances and State laws relating to building construction, Total Fee .. / LDMA Perm. # ,
< and hereby authorize represen Lives of this County to nter
u on t 7vS ntio operty fo�spection ur oses.
o �/ SEE REVERSE FOR EXPLANATORY LANGUAGE
y $
ig atu' of Applicant or Agent