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HomeMy Public PortalAbout5211 AGNES AVE_Building_0 f 1 1 WORKERS COMPENSATION DECLARATION / I� I hereby,affirm fiat I have a certificate of consent to self APPLICATION F R BUILDING P ERMI T 111 _ insure"or a certificate of Workers Compensation Insurance h 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 l� ❑ Certified copy is filed with the county building msper BUILDING FOR APPLICANT TO FILL IN ADDRESS ��// A/ tion department ADDRESS V` q/�/�S V� LOCALITY PI-6- Q NEAREST Date Applicant CITY M LG ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERSNO OF BLDGS / ASSESSOR COMPENSATION INSURANCE SIZE OF LOT -6 / NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one1� 17USE ZONE MAP /- g hundred dollars ($100)or less ) TRACT 2 BLOCK LOT NO NO !o TEL p pq ( SPECIAL I certify that in the performance of the work for which this OWNER /lar�0 oda ��/ds NO o52l!D � CONDITIONS 0. �f ,,/ /� DISTRICT GROUP YPE FIRE PRO SSED BY O permit is issued I shall not employ any person in any manner ADDRESS 52ii!Y /YCrTI(�� ��f% ONST ZONE U so as to become subject to the Work ompensation ws SS 5 2- S. CITY / MPL T �i�} ZIP �/O Aa-31 1/ -3 Q Date —Applicant STATISTICAL CLA IFICATION PT CONDO V NOTICE TO AP LICANT If after making this Cert- rate of ARCHITECT OR �i TEL ENGINEER D(, nCir- NO CLASS NO DWELL UNITS W Exemption you should become subject to the Workers d Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP with comply with such provisions or`this permit shall be TELJ Z deemed revoked CONTRACTOR a)14>o r NO BK � VALIDATION PG LICENSED CONTRACTORS DECLARATION LIC i I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VAL ATION 2Z (commencing with Section 7000)of Division 3 of the Business and LIC Professions Code and my license is in full force and effect CITY CLASS ► �� SQ FTNO NO OF CHECK License Number Lir Class SIZE STORIES FAM LIES ONE � Contractor Date DESCRI $ TION F WORK �IqA aJ���'I/L��!��i� NEW ❑ ❑ I am exempt under Sec �� C� ! ADD { L dd / ALTER ❑ FDIANAL B&P C for this reason ( 6 eklSlrn dGO,,p ©/1 REPAIR ❑ USE OF FIN ` ate f EXISTING BLDG ��P/ DEMOL E] B Signature APPLICANT TEL p r�ej O NER BUILDER DECLARAT N PRINT aPC� I✓�d-S NO LOS'G/! u�E�7J3A I hereby affirm that I am exempt from the Contractor s License ��� (� e / �/� �- Law for the following reason (Section 7031 5 Business and ADDRESS 1T e' v e o 0 0 0 Professions Code) PRESENT ❑ BUILDING a 3 2 ° 5 0 IL6 0 I as owner of the property o my employees with ADDRESS v wages as their sole compensation will do the work and 0 0 the structure is not intended or offered for sale(Section LOCALITY9 �a o a 7044 Business and Professions Code) MOVING TEL �Y I as owner of the property am exclusively contracting CONTRACTOR NO Z 0 3 2 1 -S 3 �s - with licensed contractors to construct the project (Sec ADDRESS 'tion 7044 Business and Professions Code) REQUIRED TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH Clq IvQ I hereby affirm that there is a construction lending agency for LInvestigation the performance of the work for which this permit is issued d d �� (Sec 3097 Civ C ) FD 1 v Lender s Name Lender s Address - Permit Fee �- I certify that I have read this application and state that the - Issuance Fee t S v above information is correct I agree to comply with all County Fee r� / g ordinances and State laws relating to building construction Total Fee d and hereby authorize repr eZve this County to entera u n abo mention rinspection purposes < SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicon or ADate ®: