HomeMy Public PortalAbout4847 3/8, 4853 AGNES AVE_Building_0 WORKERS COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self
APPLICATION FOR BUILDING PERMIT
insure or d certificate of Workers Compensation Insurance
or a c rtified co t (Sec 3800 C)_ - 0 - , COUNTY OF LOS ANGELES BUILDING AND SAFETpY '
Poli # Company p
do, '
BUILDING
Certified copy is hereby furnished ' 'I, t �_ FOR APPLICAN TO FILL IN _ ADDRESS �^ 3
Certified copy is filed wtthithe county building inspec " BUILDING 01
�_p
,tion department R ,t, ADDRESS Gam?
��jj t ++ t LOCALITY C
Date!�Applicant CITY �' ZIP l
a , NO OF BLDGS ,, % .. NEAREST
CERTIFICATE OF EXEMPTI N FROM WORKERS ''R SIZE OF LOT NOW ON LOT CROSS ST J'✓�
31 COMPENSATION INSURANCE t ,. �f ' ASSESSOR „ ,, ..
(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 ) - ' s �'0 TEL
F y OWNE NO USE ZONE MAP r'7 e
I certify that m,the performance of the work for which this NO lift
permit is issued I shall not employ any person in any manner ADDRESS /` CONDITIONS SPECIAI >_
+ °'
so as tofbecome subject to the Workers Compensation Lawsw / « O
- CITY , ZIP 41 j y/ s U
V'
,Date Applicant ' ARCHITECT OR TEL Y DISTRICT -GROUPK TYPE -FIRE PROCESSED BY, y 0
NOTICE TO APPLICANT If after making this Certificate of ENGINEER + NO ` t CONST Z , - '
Exemption you should become subject to the Workers ' a , [�dw
Compensation provisions of the Labor Code you mustiforth ADDRESS _ 7 c0-A J
with comply with such,provisions or this permit shall be TEL `' STATIAPT CONDO Z
deemed revoked CONTRACT NO y [ �_
r ` i LIC CLASS NO DWELL UNfTS/
LICENSED CONTRACTORS DECLARATION ADDRESS NO
I hereby affirm that I am licensed under provisions of Chapter 9 LIC SEWER MAP +v
(commencing with Section 7000)of Division 3 of the Business
and Professions Code and my license is in full for a and effect` CITY CLASS &OBK PG F�.CTILLIDATION
SQ FJ�'7d6�w NO OF NO OF CHECK 307 „ 984r9
License Number Ltc Cla SIZE ( STORIES FAMILIES ONE 7 7
",, f %, VALUATION
Contractor / DESCRIPTION OF WORK NEW $ I*i11 ,� ,�, 1 ITEMS
Elam exempt under Secl� ` ' ` e �7 ALTER 10:1 _ TOTAL 9�,. 4 ,.95
B&P C for this reason r C« REPAIR 11 $ CHECK 984■99
" USE OF
r Date j EXISTING' 0
BLDG DEMOL D CHANGE . [i
Signature APPLIC NT)ANT TELNO Z� FINAL _
OWNER BUILDER DECLARATION DATE (ki OWO-0001 8/16/39
I hereby affirm that I am exempt from the Contractor s License o J `
Law for the following reason (Section 7031 5 Business and F ADDRESS /— FINALS 5106 1 AM 9�'' '
Professions Code) " e y. ti PRESENT - - By `
1:1 ` s BUILDING •
I as owner of the property or my employees with ADDRESS - s` +�`" 1'
wages as their sole compensation will do the work and '^^ '"' " «
the structure is not intended or offered for sale(Section LOCALITY ' , 'E _�. { �A(CTrsi ,
7044 Business and Professions Code )` MOVING , -TEL
' ' CONTRACTOR NO t` Y` � 3307 1169.2`
❑ I as owner of the property am exclusively contracting -
+ with licensed contractors to construct the project (Sec " ` '�' �"' •..•`- , 1 ITEM "
ADDRESS
tion 7044 Business and Professions Code )
t REQUIRED YARD HWY TOTAL SETBACK FROM EXIST t{ - "a ���" t t +,. -,a TOTAL 1169 _5
CONSTRUCTION LENDING AGENCY , SET BACK PROP LINE WIDTH \'ti. t t� L y
I hereby affirm that there is a construction lending agency for FRONT,, * `'� `~%� i L' "`'�VCHECK �11vf7 ai ,
the performance of the work for which this permit is issued P L` t t ti y"
(Sec 3097 Civ C) SIDE _ �� > CHANGE ` ---A •00
-Pl.
Lender s Name ' M1 `
_ P C Fee$ Permit Fee ,/ LDMA Ref # 0000-Ml 8/16/89
Lender s Address T _
0 1 certify that ave read this application and state that the ` Issuance Fee b LDMA P/C# , 8107 1 AM 9:30
above info ion is rect I agree to comply with all County Investigation Fee "
Rordmanc d to aws relating to building construction Total Fee / ', LDMA Perm #
and he a on representatives of this County to enter
upon e e ntio 'property for inspection p rpos ' ' a
SEE REVERSE FOR EXPLANATORY LANGUAGE r
Signatu Applicant or Agent Date
s