HomeMy Public PortalAbout5123 AGNES AVE_Building_0 WORKERS' COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS - ley 11 .5
❑ Certified copy is filed with the county building inspec- ADBUIDLDING RESS
tion department.
CITY ZIP LOCALITY L
Date Applicant NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE 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.) TEL.
OWNER NO. USE ZONE MAP
NO.
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS }
d
so as to become subject to the Workers' Compensation Laws. O
CITY ZIP U
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIREPROCESSED BY J
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO, CONST. ZONE ty
Exemption, you should become subject to the Workers'
ADDRESS "`
Compensation provisions of the Labor Code, you must forth- ..> �� `,r `"'" ix
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. I CONDO'.-
deemed
ONDO'deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS 2
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. I
SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIG.
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK NEW ❑ $ ,
Contractor Date ADD ❑
❑I am exempt under Sec. ALTER ❑
B.BP.C. for this reason REPAIR $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL. FINALE
OWNER-BUILDER DECLARATION (PRINT) NO. DAT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT By
❑ I, as owner of theproperty, or m em to employees with BUILDING
Y p Y 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.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM JE
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE
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
� A Ref. #P.C. Fee $ Permit Fee 'Lender's AddressI certif that I have read this a lication and state that the Issuance FeeA P/C#above nformation is correct. I agpree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee A Perm. #
a and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date