HomeMy Public PortalAbout5136 AGNES AVE_Building__ WORKERS COMPENSATION DECLARATION t
7
i sueboraffcertifcatteofWorkesrtCompensationeInsurancelf APPLICATION FOR -BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company 1t
BUILDING 1
ElCertifiedcopy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS 7 „�L .f143L
❑ Certified copy is filed with the county building inspec BUILDING -
tion department ADDRESS
I
Date Applicant CITY ZIP T LOCALITY
NO OF BLDGS NEAREST
s 117-
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT O NOW ON LOT CROSS ST
COMPENSATION INSURANCE ASSESSOR p G
(This section need not be completed if the permit is for one TRACT f 7-Z6 BLOCK LOT NO Z / MAP BOOK Q �a y _ PAGE -7 PARCEL
hundred dollars ($100),or less ) _TfjL USE ZONE MAP
OWNER L / C C31Gs/QQ6 MA
I certify that in the performance of the work for which thisNO
SPECIAL >
permit is issued I shall not employ any person in any manner ADDRESS —7 / CONDITIONS - a
so as to become subject to the Wor rs Com nsatic;n Laws OU
�
CITY ZIP
Date Applicant ARCHITECT OR TEL - DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO CONST ZQNE
.e--
Exemption you should become subject to the Workers U
Y I jw ,P 3w
Compensation provisions of the Labor Code you must forth ADDRESS K
with comply with such provisions or this permit shall be / _TEL , STATISTICAL CLASSIFICATION APT CONDO 'Z Y
deemed revoked CONTRACTOR M5 L / NO Z t —
LICENSED CONTRACTORS DECLARATIONNCO��,���� CLASS NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 7
(commencing with Section 7000)of Division 3 of the Business pp LIC SEWER MAP
and Professions Code and my license is in full force effect CITY &00r t>16,._ CLASS BK E PG VALIDATION
��Qf :_31
/ _ SFT OF OF CHECK
License Number (](p ` Lic Class Gr SI ST FAZE STORIES FAMILIES ONE
N EV�zycl�sDyrtalb S !/ VALUA ION
Contractor, i ate _ DESCRIPTION OF WORK °1 j�� NEW ❑ a !`yut 1
ADD ❑ (/(/(/ i
❑I am exempt under Sec Q+V�04
ALTER
�r B&P C for this reason
REPAIR ❑ $
Date USE OF
r EXISTING BLDG DEMOL ❑
f
Signature a.4A.6M/ APPLICANT TEL - FINAL
OWNER BUILDER DECLARATION (PRINT) �w� NO
DATE
I hereby affirm that I am exempt from the Contractor s License I - - -S -
�
Law for the following reason (Section 7031 5 Business and ADDREFINAL
Professions Code) PRESENT By BUILDING
❑ -- — r
I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and I + -
the structure is not intended or offered for sale(Section LOCALITY -
7044 Business and Professions Code ) MOVING -- TEL �I ��—�
❑ I as owner of the property am exclusively contracting CONTRACTOR NO i _
cr
with licensed contractors to construct the project (Sec ADDRESS µ - N a` t L `
tion 7044 Business and Professions Code ) t
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST - P Ilii IG
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
(Sec 3097 Civ C ) SIDE
Lender shame LDMA Ref #
P C Fee$ Permit Fee
Lender s Address
j certify that I have read this application and state that the Issuance Fee LDMA P/C# pool
8 above information is correct I agree to comply with all County Investigation Fee C
R ordinances and State jaws relating to building construction Total Fee v7 / LDMA Perm #
a and here))y authorize representatives of this County to enter y
upon t obove me one property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of Applicant or Agent Date