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HomeMy Public PortalAbout4901 AGNES AVE_Building__ r�.+� 04PRKERS'COMPENSATION DECLARATION ry/lins re,orafcertifcathatteofA kes�, oJ 16 aoite �&tioneInsuran ont to f APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) i COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL INADDRESS - 4901 N. Agnes Ave. Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 4901 N. Agnes Ave. p Temple City, Ca. Date Applicant CITY Tem Crit ZIP l 80 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 60 X l60 NOW ON LOT 1 CROSSSST.Lower Azusa COMPENSATION INSURANCE p p (This section need not be completed if the permit is for one TRACT 8l�8 BLOCK LOT NO. ASSESSOR hundred dollars ($100)or less.) 9 24 MAP BOOK 1 PAGE67/68 PARCEL TEL. USE ZONE MAP I certify that in the performance of t e ork for which this OWNER K NO. 2 6-008 NO. permit is issued, I shall not employ any p rson in, ny manner SPECIAL d} so as to become subject to the Worked '� m noMian Laws. ADDRESS same �+� CONDITIONS O 6/3/87 K:"Kim CITY ZIP U Date Applicant NOTICE TO APPLICANT: If, after aki g this Certificate of ARCHITECT OR TEL. DISTRICT G OUP TYPE FIRE PROCESSED BY O ENGINEER a NO. /, CONST.' ZONE Exemption, you should become s i ct to the Workers' O ' Compensation provisions of the Labo ode, you must forth- ADDRESS V with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFIC TION APT, JINDO. Cn deemed revoked. CONTRACTOR a NO. z: LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS — 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 _ CLASSBK VALIDATION SQ. FT. O. OF NO. OF CHECK License Number Lic.Class SIZE STORIES 1 FAMILIES 1 ONE r�Sr� itci n ows ryw I W— VALUATION Contractor Date D IPI WORK en: new cabin i ❑ $ 6, 06 I am exempt under Sec. & counter, floor tile, drop ce 1lEng�❑ , . LTER B.BP.C. for this reason ?I oor tile_,,_s1Wlight. REPAIR ❑ $ Date: USE OF neW Support beams, DEMOL 1 I1 EXISTING BLDG. pp ❑ 7 1 8 r� Signature APPLICANT YDAn K. TEL. �+ FINAL OWNER-BUILDER DECLARATION PRINT m NO. 286"0087 DATE ✓ # a a a ©,o 5 I hereby affirm that I am exempt from the Contractor's License 4901 N• Agnes, Temple City Law for the following reason (Section 7031.5, Business and ADDRESS FIN °;a 7 8.0 0 Professions Code): R BY BUILDING same ° °'° 7 a 0 0= a I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY TB le C]t 06,03-87 the structure is not intended or offered for sale(Section 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). SETBCK FROM EXIST. CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAREQIREPROP .I NE WIDTH 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 m LDMA Ref. a P.C. Fee$ Permit Fee S� Lender's Address 3 g I certify that I have read this application and state that the Issuance Fee �O LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee �j a ordinances n State laws relating to building construction, Total Fee l/ LDMA Perm. fi N and hereby ut horize re sentotives of this County to enter M upon the ab v - enti ntf r perty f r inspection purposes. 6/x%87 SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur of pplicant or Agent Date _ 1��