HomeMy Public PortalAbout5128 AGNES AVE_Building__ WORKERS COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent To self APPLICATION FOR BUILDING P E RM I T
m"sure or-a certificate of Workers Compensation Insurance � ..,
or a,certified copy thereof (Sec 3800 Lab C ) _ COUNTY OF LOS ANGELES BUILDING AND SAFETY
'Po9c'y No Company '
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS'
❑ Certified copy is filed with the county building mspec BUILDING ADDRESS 1 Z-� em
tion department r
Date Applicant y - CITY ZIP 7 Q LOCALITY'
NO OF BLDGS NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT - CROSS ST
COMPENSATION INSURANCE f,
ASSESSOR
r (This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOOKPAGE r PARCEL `
hundred dollars ($100)or less ) i OWNER / M T LNO 2 j7 US ONE MAP ,
NO
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 5 CONDITIONS 0-
so
so as to become subject to the Workers Compensation Laws 0
CITY ZIP ' e _
Date Applicant ARCHITECT OR TEL DISTRICT G UP TYPE FIRE ROCESSED BY 0
NOTICE TO APPLICANT If after making this Certificate of - ENGINEER NO s ��(/� �� CONSt4% ZQ[�E f /t /7 U
Exemption you should become subject to the-Workers y 6/j� `-/p/` `={/ t�V�f"/r U
Compensation provisions of the Labor Code you must forth ADDRESS a.
with comply with such provisions or this permit shall be TEL STATISTICAL CLAS CATION APT CONDO N
deemed revoked CONTRACTOR NO Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO w 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 LIC
SEWER MAP
and Professions Code and my license is in full force and effect CITY CLASS BK �! PG VALIDATION
SQ FT NO OF NO OF CHECK _
License Number Lic Class SIZE STORIES FAMILIES ONE
VALUATION
' DESCRIPTION OF WORK NEW ❑
Contractor Date $
C ADD ❑ ,
❑I am exempt under Sec G
ALTER ❑ -'
B&P C for this reason REPAIR ❑ $
Date
USE OF
r EXISTING BLDG DEMOL ❑
Signature APPLICANT 4 TEL FINAL '
OWNER BUILDER DECLARATION (PRINT) NO
DATE ql
I hereby affirm that I am exempt from the Contractor s License '' I7
Law for the following reason (Section 7031 5 Business and ADDRESS FINAL ':t i�
P�rJo�fe�sSions Code) PRESENT _ _ By 1 ITEMS
9 I as owner of the property or m employees with BUILDING
P P Y YADDRESS T(ITAL - ® �
wages as their sole compensation will do The work and
LOCALITY L1 -c}
the structure is not intended or offered for sale(Section MOVING _ TEL ( ASH .0
7044 Business and Professions Code ) -- - -
CONTRACTOR NO CHANGE
I
I as owner of the property am exclusively contracting f7t'ttr •�
with licensed contractors to construct the project (Sec `
tion 7044 Business and Professions Code ) ADDRESS
t�'-y�-}�y���}� 8 Pr
REQUIRED YARDc HWY TOTAL SETBACK FROM EXIST 00100—Owl 10/19/E9
CONSTRUCTION LENDING AGENCY SET BACK PROP LINE 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 62K _1 AM 9:06
(Sec 3097 Civ C ) SIDE
PL
Lender s Name
LDMA Ref #
PC Fee$ Permit Fee
Lender s Address ,
1 certify that I have read this application and state that the Issuance Fee / LDMA P/C#
8 above information is correct I agree to comply with all County Investigation Fee a
R ordinances and State jaws relating to building construction Total Fee 49 r LDMA Perm #
aand hereby authorize representatives of this County to enter
m upon the ntio pr erty for inspections pur oses
Gf LD A 7,�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date