HomeMy Public PortalAbout4859 AGNES AVE_Building_0 WORKERS' COMPENSATION DECLARATION
lf
insure, or acertificate affirm
of Workers' Compensation I have a certificate of Insurato ncee, APPLICATION FOR BUILDING PERMIT
or.a certified
copy_th f (Sec. 3800, Lab. C,.)� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nd!` Compony �'C�'p "�--
BUILDING
El Certified "")
Certified copy is hereby furnished. .FOR APP T TO ILL IN ADDRESS (,f / Q ,v
Certified copy is filed with the county building inspec- BUILDING
%RgTIFIATE
ent. ADDRESS
c)(
ZIP
Date
Ce,
LOCALITY
CITY ` NO. OF BLDGS. NEAREST
OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR `
(This section need not be completed if tFie permit is for one TRACT BLOCK LOT NO. MAP BOOK5�� PAG PARCEL
hundred dollars ($100) or less.) TEL
OWNERy% NO Z!/ USE ZO E MAP
I certify that in the performance of the work for which this /-n l / SPOECIAL >_
permit is issued, I shall not employ any person in any manner ADDRESS f'(/C (�� CONDITIONS IL
so as to become subject to the Workers' Compensation Laws. rpq v ;
CITY U ZIP `
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT:.If, after making this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE ES BY
g CONST. ZONE 0
Exemption, you should become subject to the Workers' �� G w
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be c TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTO 7� NO. ) _
LICENSED CONTRACTORS DECLARATION LIC. .� CLASS NO. Z3 DWELL. UNITS
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP '7
,J / -
and Professions Code,and my license is in full force and effect. CITY CLASS �gK pG ( VALIDATION
SQ. FT NO. OF NO: OF / CHECK
License Number 7 'f[ �J � tic. Cla SIZE STORIES FAMILIES / ONE
4ex
_ VALUATION
Contractor 9v Dot t DESCRIPTION OF WORK U NEW 1:1
❑I am exempt under Sec. ADD�t, ❑ $ ►
ALTER; ❑
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF �/-� DEMOL
EXISTING BLDG. 0/
Si nature APPLICANT I/ TEL
9 (PRINT). �T/� �J NO. (! / T?� FINAL
OWNER-BUILDER DECLARATION DATE
7
I hereby affirm that I am exempt from the Contractor's License ADDRESS CM/ /' c��� ,s� a
Law for,.the following reason (Section 7031.5, Business and FIN
Professions Code): PRESENT By, _ >
BUILDING
❑ I, as owner of the property; orl my employees with ADDRESS
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.
CONTRACTOR NO.
❑ I, as owner of the property, am exclusively contracting ,,
with licensed contractors to construct the project (Sec- .. 50
tion 7044, Business and Professions Code.) ADDRESS
F „t
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. l „5'-i
CONSTRUCTION LENDING AGENCY SET BACK 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 � r-'-
m (! D.
LDMA Ref. #
P.C. Fee$ Permit Fee
Lender's Address -- t•I12
0 1 certify that I have read this application and state that the Issuance Fee O J v LDMA P/C# Pol
8 above information is correct. I agree to comply with all County Investigation Fee '
R ordinances State I s relating to building construction, Total Fee U• LDMA Perm. #
< and hereb uthor' presentatives of this County to enter
upon th'e ove a oned property for inspection purposes.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatui pplicant or Agent Date