HomeMy Public PortalAbout4906 AGNES AVE_Building__ �d dFk' •ERS'COMPENSATION DECLARATION y,
hereby affirm that I have ycertificate of consent to self APPLICATION FOR BUILDING--PERMIT• CU
• insure, or 'certificdte of Workers' Compensation Insurance;
or a certified copy thereof (Sec. 3800,'Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY--N.
Policy No. Company
'Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
DateApplicant CITY r� !F� C.. ` ZIP % CO LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' O. OF BLDGS. / NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS,ST. 4 A-
(This section need not be completed if the permit is for one - ASSESSOR,
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
✓� TEL. ✓1
I certify that in the performance of theP
OWNER �� p5
work for which this USE ZONE MA
NO NO. >,
permit is issued, I shall not employ any person in any manner ® / SPECIAL - �
so as to become subject to the Workers'Compensation ws. ADDRESS C�II�` CONDITIONS O
Date pplica �� CITY L r C/ ZIP
/ / ®.._ r V
ARCHITECT OR j TEL. O
E TO' PLICANT: If, after making'this Certificate of ENGINEER �L NC� ,� DISTRICT GROUP TYPE FIRE PR E ED BY_
mption, you should become subject to.the- Workers' '^D� CONST.' ZONE V
Compensation provisions of the Labor Code,.you must forth- l a �� f lu
with comply with such provisions or this permit shall be ADDRESS
deemed revoked. L N L STATISTICAL CLASSIFI ATION APT. NDO.
CONTRACTO
LICENSED CONTRACTORS DECLARATION p ; L O o, CLASS NO.—DWELL. UNITS
I herebyaffirm that I am licensed under provisions of Chapter 9 ADDRESS 7
(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 VALIDATION
-
SQ. FT. NO.OF NO. OF CHECK BK. PG.
License Number Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
"
Contractor Date DESCRIPTION OF WORK A . X NEW a
'
I < ADD
I am exempt under Sec. /� ❑ -
ALTER
B.&P.C. for this reason I REPAIR Q $ '
Date: USE OF
EXISTING BLDG. ZEE, DEMOL
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRIM /t G NO. DATfi
629
. ..1 A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRE A FINA ' # 0 0 0 0 0 1 '
Profe ions Code): PRESENT By '` 3'� 5
' 1 ', as owner of the property, or my employees with ADDRESS 0
wages as their sole compensation,will do the work and LOCALITY oil. ° ° 1 3 4,2 5:5i
the structure is not intended or offered for sale(Section
--,/7044, Business and-Professions Code). MOVING TEL: -
1 i�l I, as owner of the property, am exclusively contracting CONTRACTOR NO. O 1.Q.b—8 7
LW with licensed contractors to construct the*project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED YARD HWY TOTAL SETBACK FROM T.
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
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
o' LDMA Ref. #
m - - - P.C. Fee$- - Permit Fee - - - - - -
Lender's Address
> h ......
I certify that I have read this application and state.that the Issuance Fee V (/ LDMA P/C N
a above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee 3 .e�-� LDMA Perm. H '
U and hereby authorize representatives of this County to enter
m upo the above-ment' ed pr erty fo nspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Applicant or Agent DS - - -- - @ i
f"i.