HomeMy Public PortalAbout6263 AVON AVE_Building_11/21/1983_reroof WORKERS COMPENSATION DECLARATION
ereby affirm that I have a certificate consent self APPLICATION FOR BUIL ING P E RM I T
We or o certificate of Workers Compensation Insurance I
a certified copy thereof (Sec 3800 Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY -
P. y r&,V83-225154compamFremont TndPmni ry t A BUILDING
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS 6 Z
n Certified copy is filed with the county building inspec BUILDING r
l�J r
tion department ADDRESS LOCALITY
Date 11/16/83 ApplicantVirgjn Roof CO. CITY Temple Cit ZIP CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE IZE OF LOT�`J X �� NOW ON LO MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one �• , USE ZONE MAP
hundred dollars ($100)or less ) TRACT l7 BLOCK L T NO '3 NO ZcJ
TEL R I SPECIAL
I certify that in the performance of the work for which this OWNER Shirle Crawford NO CONDITIONS IL
permit is issued I shall not employ any person in any manner - - DISTRIC GROUPYleTYPE FIRE PROCESSED BY 0 1
so as to become subject to the Workers Compensation Laws ADDRESS CONST adV
„ CITY San L`1<a O 110 ZIP O
:]
Dote Applicant STATISTICAL CLASSIFICATION APT CONDO 1�,
NOTICETO APPLICANT If after making this Certificate of ARCHITECT OR TEL '' U
Exemption you should become subject to the Workers ENGINEER NO CLASS NO.DWELL UNITS LU
Compensation provisionsiof the Labor Code you must forth ADDRESS - - - - v h SEWER MAP
with comply with such provisions or this permit shall be Z
deemed revoked CONTRACTOR TEL
BK« PG w VALIDATION
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS p Q BOX J NO 160650 VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code and my license is in full force and effect CITY Sap Cnhrl P1 9177R CLASS $ 1747.00
160650 SQ FT NO OF NO OF CHECK
License Number Lic Class 639 SIZE STORIES FAMILIES ONE
ContractorVirgin ROOF CO. Date 11/16/83 DESCRIPTION OF WORK — ~
NEW $
1 am exempt under Sec ' Class A`Fiber lass ADD
ALTER F] FINAL �r
B&P C for this reason Com osition shingles (14USE OF S ),AIR DATE
Date C
EXISTING BLDG — _ DEMOL FINAL
Signature APPLICANT TEL By $ Q
g OWNER BUILDER DECLARATION (PRINT) NO — �j0 Q' o
t ®
Law for the following reason (Section 7031 5 Business and ADDR
I hereby affirm that I am exempt from the Contractor s License ESS P. Q• Bol[ J, San Gabriel 91778 F b
Professions Code)
BUILDING a a . 9 8
wages-as I as owner of the property or my�employees with r ADDRESS d _Y r
as their som
le copensation will do the work and �
the structure is not intended or offered for sale(Section LOCALITY a 0 0 (( 9 8
7044 Business and Professions Code) ' MOVING TEL
I as owner of the property am exclusively contracting CONTRACTOR " NO ` M ° ` I 21
with licensed contractors to construct the project (Sec s a 1 r t
ADDRESS
tion-7044 Business and Professions Code) , t Y
r REQUIRED TOTAL SETBACK FROM EXIST u`
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 o
(Sec 3097 Civ C ) SIDE 1 ~f
r
9
Lender s Name
T PC Fee$ Permit F..--30-.39-
l5 .tee' iY
Lender s Address 4
l�
I certify that I have read this application and state that the Issuance Fee 110.50 « T
a above information is correct I agree to comply with all County Investigation Fee y w t
ordma ces and State laws relating t building construction b _ 49"88
IJ and h reby authorize representatives f this County to enter Total Fee . r r t
u FLefabove mentioned o erty f i ction purposes
t,
SEE REVERSE FOR EXPLANATORY LANGUAGE _ w �l #r A
Si ture of Applicant or Agent Date r rS es
r � i