HomeMy Public PortalAbout4847 1/2, 4855 AGNES AVE_Building__ - / t
F WORKERS COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self MA P P L I CATION FOR B U I L'D I N G PERMIT f
insure of a certificate of Workers Compensation Insurance �„
or a certified co the f (Sec 3 b C ) ° `
I COUNTY OF LOS ANGELES BUILDING ANDS FETY
Poli Company
❑ Certified copy is hereby furnished FOR APPLICANT JO FILL-IN BUILDING
ADDRESS K rx
Certified copy is filed with the oWr/u iyrjgySPec - BUILDING r xt __ 4• _
d*FICATIE�
ent G top GQ ADDRESS t
r
° ZDateApplicant LOCALITYNO OF B DGS w r NEARESTW ��OF EXEMPTION FROM WORKERS SIZE OF LOT NOW F LOT CROSS ST
COMPENSATION INSURANCE 0 ASSESSOR ,
(This section need not be completed if the permit is for one TRACT BLOCK + LOT NO ` MAP BOOK PAGE 3n PARCEL
hundred dollars ($100)or less ) ° TEL
OWN /« NO Z USE MAP
NO
P r c i
I certify that in the performance of the,work for which this
permit is issued I shall not employ any person in any manner ADDRESS SPECIAL
- CONDITIONS
so as to become subject to the Workers Compensation Laws Q
f ' S CITY c - ZIP /d 14.0 U -
Date °' ` -iApplicant - ° ARCHITECT O EL +
NOTICE TO APPLICANT If after making-this Certificate of ENGINTYPE
EER NO - DISTRICT ROUP CONSTy ZONE FIRE PROCESSED BY -
Exemption you should become subject to the Workers r
Compensation provisions of the Labor Code you must forth ADDRESS L 7 a a
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION Y APT CONDO Z t
deemed revoked :` , CONTRACT NO - • / a
'LICENSED CONTRACTORS DECLARATION r LIC CLASS NO " DWELL U TS ( ��~ a
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
and Professions Code and my lice i in fullyforce a effect s CITY CLASS BK VALIDATION
r SQ FT /� NO OF NO OF CHECK
License Number Lic CI ^ SIZE �V STORIES FAMILIES ONE ' r
+ a VALLI TION /�A6�aT �\
Contractor Date — ��" DESCRI ION OF WORK + NEW $° �,JJ ��y�` ACC I �ryC� /)
t � ADD- ❑ + _ ,T ;307 689.47
❑I am exempt under Sec l
B&P C for this reason Z , ALTER ❑ L t . r
r REPAIR 1-1 $ 1 ITEM
USE O
Date _ EXISTING BLDG ,y DEMOL ❑ R TOTAL 689.47
Signature t~ APPLICANT TEL FINAL "
OWNER BUILDER DECLARATION (PRINT) NO u/ r ,/V( � ��E�k �$�j°¢7
I hereby affirm that I am exempt from the Contractor s License _
DATE
Law for the following reason (Se6ttion 7031 5 Business and ADDRESS �+ r M FINAL, CHANGE °4O
t Professions Code) 7, - PRESENT ,. _ _ ,. By I
BUILDING
I as owner of the property or my employees with ADDRESS °
wages as their sole compensation will do the work and - �-- --» - T,+«.-d r T 1 4 +0080'0001 8116/89
the structure is not intended or offered for sale(Section LOCALITY r 1 t M °.,,,
❑ 7044 Business and Professions Code ) MOVING _ _ TEL __ ' ° - A 1�1�11 1 AM 9■32 R
CONTRACTOR NO
I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code ) '
REQUIRED TOTAL SETBACK FROM EXIST ° _ _P -��'\F` ` � '� ; CT°* '
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH _ `� "►�
I hereby affirm that there is a construction lending agency for FRONT �.� �� ���`, 3\307 w 1169°
the performance of the work for which this permit is issued PL 1 ITEMS—,,
(Sec 3097 Civ C) SIDE
PL -� - TOTAL. 1169:-9
Lenders Name � F [ IVY 1169 rt:
_ t
�. + ? PC Fee
$ O, v T Permit FeeLDMA Ref # __ , _ •+
Lender s Address ^ I--.<gCHANGE - °Ort
a 1 certify that I have read this application and state that the r Issuance Fee 'Sd LDMA P/C#
0
8 above inf ation correct I agree to comply with all County ► Investigation Fee / L 3/16/°p
R ordinan to jaws relating to building construction Total Fee t LDMA Perm # + 0000-0�1 N
and h y auth ze representatives of this Count to enter +.+9
upo a abov a ned property for inspectio 9112 1 AMS
`SEE REVERSE FOR EXPLANATORY LANGUAGE M "
Signa ure of Applicant or Agent 4