HomeMy Public PortalAbout4857 AGNES AVE_Building_8/16/1989_ WORKERS COMPENSATION DECLARATION '
I hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT
• insure or a certificate of Workers Compensation Insurance r
dr a:er ified copy the' f (Sec 3800 ab C) r ,� - COUNTY OF LOS ANGELES BUILDING AND SAFETY ,
Policy TQo'�2Company j P�
❑ Certified copy is hereby furnished. FOR APPLI ANT O FILL IN - * BUILDINGN�
ADDRESS
It
r _ BUILDING ti ^s
Certified copy is filed with the county building inspec ADDRESS
to d rtment _
Dat oApZIP
plicaniril CITY L C NO OF BLDGS - r LOCALITY * e
CERTI ICATE OF EXEMPTION FROM WORKERS ' SIZE OF LOT NOW ON LOT ' ' CROSS ST
COMPENSATION INSURANCEASSESSOR Q� �s J
(This section"need not bet completed if the permit is for one ' TRACT^ + BLOC LOT NO " MAP BOOK V 1 PAGEv `�✓ PARC `
hundred dollars ($100)or less ) `}
TEL
OWNER - NO USE NE MAP PECIAL -,
1 certify that in the performance of the work for which this a NO
I, S
permit is issued I shall not employ any person m any manner ADDRESS ! CONDITIONS 0
"so as to become subject to the Workers Compensation Laws r r / V
> ' r CITY Ntr v c ZIP U .s _
Date+ Applicant - i ARCHITECT OR TEL r DISTRICT GROUP TYPE FIRE SSED BY " 0
,NOTICE,TO APPLICANT If after makingthis Certificate of ENGINEER + NO + G
CONST ZONE �,
Exemption you should become subject to the,Workers ��^
Compensation provisions of the Labor Code you must forth ADDRESS' ' DO -�3 �� M
with comply with such provisions or this permit shall be TEL ' STATISTICAL CLASSIFICATION APT CONDO Z
deemed revoked CONTRACTOzi6 NO h a+� ��
LICENSED CONTRACTORS DECLARATION LIC /� CLASS NO x+23-'DWELL UNITS ^t
I hereby affirm that I am licensed under provisions of Chapter 9 _ ADDRESS NO"C i
(commencing with Section 7000)of Division 3 of the Business LIC
L SEWER MAP _ y sr
r
and Professions Code and my license is in full force and effect CITY CLASS / E-BK PG 5 VALIDATION
SQ FT NO OF NO OF CHECK
License Numbe �ZaLic Class SIZE _ STORIES FAMILIES ONE 4
,� p I VALUATION r �,
Contractor - p tP D^� A DESCRIPTION OF WORK �Y� (! NEW T❑
❑ _ r _ ADD— 1-1s ► �
I am exempt under Sec
ALTER ❑ +- -
B 8P C for this reason $
USE OF REPAIR ❑ t y r
Date EXISTING BLDG DEMO L' e"
Signature APP(PRINT) O/�NO 2 IF
TELr FINAL V _�J
OWNER BUILDER DECLARATION v 40
DATE
I hereby affirm that I am exempt from the Contractor s License Z� �4 aN,,a"
ADDRESS
L"aw for the following reason (Section 7031 5 Business and FINA
Professions Code) ` PRESENT ._ _ By , A
Uzz
t
`I as owner of the property or my employees"with r ADDRESS k t 4s
wages as their sole compensation will do the work and a
the structure is not intended or offered for sale(Section LOCALITY 4
7044 Business and Professions Code ) - - ° , MOVING 4 _ TEL
❑ I as owner of the property am exclusively contracting CONTRACTOR ' NO
with licensed contractors to construct the project (Sec ADDRESS - *- 4 - ' - _ .- f j(r 4t +0
tion 7044 Business and Professions Code
) REQUIRED TOTAL SETBACK FROM- _EXISTs(-p=i-1
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH
ti
I hereby affirm that there is a construction lending agency for FRONT _ - " ^ s^ i#f +t , Ott
the performance of the work for which this permit is issued P L`
(Sec 3097 Civ C ) SIDE
s P L
Lender s Name
PC Fee$ Permit Fee LDMA Ref #� L „7,;
Lenders Address r, -
c I certify that a e read this application an'd state that the Issuance Fee G �v LDMA P/C#~ + `
8 above info' ati orrect I agree to comply with all County Investigation Fee - r - , r +r
R ordinanc Stat jaws relating to building construction Toral Fee 1,5
LDMA Perm # +
and he uthon a re sentatives of this County to enter F
up n e ove nti ed property for inspection purposes
^"SEE REVERSE FOR EXPLANATORY LANGUAGE °
Signal of App scant or Agent Date
s f a`