HomeMy Public PortalAbout4851 AGNES AVE_Building_3/16/1989 i
WORKERS COMPENSATION DECLARATION j t
hereby affirm that I have a certificate of consent to self APPLICATION F O R� BUILDING PERMIT
�insure or a certificate,of Workers Compensation Insurance
or a certified copy t piiof(Sec 38001 Lqb C ) COUNTY OF LOS ANGELES" BUILDING AND SAFETY
Policy N Company
+ BUILDING
E] Certified copy i hereby furnished i FOR APPLICANT TOf ILL IN ADDRESS O
❑ Certified copy is filed with the county building inspec BUILDING
tion department
ADDRESS
"Date 6 Applicant CITY / 4 + ZIP LOCALITY' / ` • r `
CERTI KATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOTNO OF S _ CROSS NEARESST
+ `y COMPENSATION INSURANCE ti ASSESSOR , / //'' '/
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOOK PAGE 60 PARCI4/� 7"
hundred dollars ($100)or less ) TEL
a OWNER NO Z.(` USE ZONE MAP
I certify that in the performance of the work for which this ; NO
permit is issued I shall not employ any person in any manner ADDRESS s "SPECIAL + a.
so as to become subject to the Workers Compensation Laws ® ,� - CONDITIONS y O
CITY ZIP U
Date Applicant - ARCHITECT OR TEL a
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO DISTRICT GROUP CTMOPNS7 ZONE SED BY O
Exemption you should become subject to the Workers ? e ��� �;7 + w
Compensation provisions of the Labor Code you must forth ADDRESS w f �� _ a
with comply with such provisions or this permit shall be Y TEL STATISTICAL CLASSIFICATION APT CONDO to
deemed revoked �> Jr CONTRACTOR NO z
LICENSED,CONTRACTORS DECLARATION ' ` IC ' CLASS NO DWELL UNITS
+I hereby affirm that I am licensed under provisions of Chapter 9 s ADDRESS SEWER MAP
(commencing with Section 7000)of Division 3 of the Business / LIC j
and Professions Code and my I ense is in full%force and effect ,, dIITY UCLASS BK 'PG VALIDATION
SQ Fi O OF NO OF CHECK
License Number Lir CI Y SIZE STORIES FAMILIES ONE S
.� •~- - VALUATION , /'/)�i�J 46 7-0 O
Contractor DESCRIPTION OF WOR NEW i ❑ $ + `
❑I am exempt under Sec " - » ADD ❑ Y ��� ��� `
❑
B&P C for this reason - y J ALTER REPAIR ❑ $_ i 3,10Q
A USE OF - a
4 Date EXISTING BLDG ' DE NOL
Signature r APPLICANT TEL f4l J FIN L -7 NO 77
f
OWNER BUILDER DECLARATION
^ DATE del '
I hereby affirm that I am exempt from the Contractor s License
Law fo`r the following reason (Section 7031 5 Business and ADDRE» IVB ��•� pl f
Professions Code) PRESENT
BUILDING
I as owner of the property or my employees with , ADDRESSw �A _
» wages as their sole compensation will do the-work and "` " , _
the structure is not intended or offered for sale(Section LOCALITY ,MOVING TEL x,14 _�# +v till +i
❑ 7044 Business and Professions Code ) a CONTRACTOR ' NO -�1 +I.
I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec - 't ,
43
tion 7044 Business and Professions Code ) ADDRESS �(' _v
w T REQUIRED o YARD HWY TOTAL SETBACK FROM EXIST r j( V' ie'La�t i
CONSTRUCTION LENDING AGENCY SET BACK PROP LINE WIDTH 't
I hereby affirm that there is a construction lending agency for c FRONT M _ t » _ 2W4,F4; tr # I
the performance of the work for which this permit is issued PL
(Sec 3097 Civ C ) r SIDE + +
P LS
Lender s Name -Xi;t_ ...( i rte
$ P C Fee$ 4 Permit Fee LDMA Ref-q »
Lender s Address M ' /�� r�, t"ti 'rii'� -
I certify thJIve rea is application and state that the Issuance Fee 0-_ LDMA P/C#
8 iabove infon is rrect I agree to comply with all County InvestigationFee Tordinancet a jaw relating to building construction Total Fee � ' LDMA Perm Nand herebrize re es ntatives of this County to enterupon theaendo a roperty for inspecti�Zu,`N v y !SEE REVERSE FOR EXPLANATORY LANGUAGE
i ature of scant or Agent Date
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