HomeMy Public PortalAbout4835 AGNES AVE_Building_7/16/1970_ WORKERS'C SATION DECLARATION
r�I F rlsbo ca certificate
that Seg r certificate of consent to Self APPLICATION FOR BUILDING PERMIT
v'
insdF�, or a certificate of Workers' Compensation Insurance,
ora certified copy thereof (Sec. 3800, Lab. C.)' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT-TO FILL IN BUILDING
❑ ADDRESS ✓
Certified copy is filed with the county building inspec- BUILDING Yn/
tion department. ADDRESS �/V
Date Applicant CITY , ZIP / O LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. I SIZE OF LOT If/O NOW ON LOT CROSS NEAREST
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one TRACT P '96 ASSESSOR
hundred dollars ($100)or less.) BLOCK LOT NO. MAP BOOK GE PARCEL
TEL. / USE ONE MAP
I certify that in the performance of the work for which this OWNE K G T v J NO,
NO. 2
permit is issued, I shall not employ any person in any manner /� SPECIAL
so as to become subject to the Workers'Compensat'on Laws. ADDRESS C9 CONDITIONS 0
Date `® Applican CITY . ZIP 70
ARCHITECT OR /TEL.
NOTICE A PLICANT: If, after making this Certificat r �� �g�D� NO. ISTRICT GR UP TYPE FIRE 7ESSEbBY O
ENGINEER
Exemption, you should become subject to the Workers' �j //,� � CONST. ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS ✓�V� ✓ Li l_
with comply with such provisions or this permit shall be
deemed revoked. CONTRACTOR a� R(�/� O STATISTICAL CLASSIFICATION APT. CONDO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. Z DWELL. UNITS Z
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS
SQ. FT. NO.OF NO. OF CHECK BK. C PG. VALIDATION
License Number Lic.Class SIZE TORIES FAMILIES ONE
Contractor Date DESCRIPTION OF WORK NEW ❑ VALUATION OU 9 77 3.7 As t`� 4'r
p M . jFAo4 ADD ! a ' # a 4i® 80
❑ I am1exem t under Sec. ALTER ❑
BAP.C. for this reason ,,USE OFQ / REPAIR ❑ $
( ° 2 4 4 8 0
Date: EXISTING BLDG. e1 N' DEMOL ❑ °.a 2 4 4,8 0 5
Signature APPLICANTA n l TEL. FINAL
OWNER-BUILDER DECLARATION PRINT /GFi NO. -�`�s� DAT o� 0 8 2 5 8 7
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FIN
Professions Code): _ gy
BUDDING g�J� 1Q ;2 8 1 .Q 7 A
I, as owner of the property, or my employees with ADDRESS � 112`''J � C '
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY # o 0 0 •,e'1
7044, Business and Professions Code). MOVING /� TEL.
r7I, as owner of the property, am exclusively contracting CONTRACTOR NO. `4 - 28200
with licensed contractors to construct the project (Sec- ADDRESS _
tion 7044, Business and Professions Code). o 0 2 82 0,0 c�
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT !.) O'1 (( 8 7
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
��� /�
P.L..
Lender's Nome ••�-�
P.C. Fee$ t Permit Fee LDMA Ref. #
Lender's Address '
I certify that I have read this application and state that the Issuance Fee c LDMA P/C#
o above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee
R and hereby authorize representatives of this County to enter LDMA Perm. #
m upon the above-menfio raper y for inspection purposes.
' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Ag nt ate