HomeMy Public PortalAbout5219 AGNES AVE_Building__ WORKERS"COMPENSATION DECLARATION v�
�L or afcertif cirm arte of Workers' Comtpensat on ensuran t to elf APPLICATION I O N F®R BUILDING PERMIT
certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING i
ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
Date Applicant CITY LZIP 7,�Fe) LOCALITY i 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. / NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT / CROSS ST.
(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.OWNER p/� USE ONE MAP
V�/lid/
I certify that in the performance of the work for which this NODNO.
permit is issued, I shall not employ any person in any manner SPECIAL
so as to 6 20 e subject to the Workers'Compensation L ws. ADDRESS d t CONDITIONS
CITY L ZIP
DatApplicant
NOT E O APPLICANT: If, after mak' g this Certificat of� ARCHITECT OR TEL.ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY O
VExemption, you should become subject to the Workers' % 2 � �CONST. ZONE 1
Compensation provisions of the Labor Code, you must forth- ADDRESS l' Ld
with comply -with such provisions or this permit shall be 0-'
deemed revoked, TEL. STATISTICAL CLASSIFICATI N APT. I/CONDO. fq
CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO._1_DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC..
Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. O. OF NO. OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE _
VALUATION l s a l (
NEW E Q
Contractor Date DESCRIPTION OF WORK ADD ) • / '�2' � 8 iii
MI am exempt under Sec. E]ALTER $ ® ® o o 6 a 6 3�
B.BP.C. for this reason $
REPAIR � '0 1,06-88.
Date: USE OF 0
EXISTING BLDG. DEMOL
Signature APPLICANTTEL. ,/� FINAL
OWNER-BUILDER DECLARATION PRINT) NO. vV5� �iCJ DATE ?
I hereby affirm that I am exempt from the Contractor's License /
Law for the following reason (Section 7031.5, Business and ADDRESS l7 FIN
PRESENT
PP fessions Code): B �f1 �/ ;2�6
BUILDING i r 8
I, as owner of the property, ormy employees with ADDRESS «
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY ' 6 3 6
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).
REQUIREDTOTAL SETBACK
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY 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 1
P.L. i
Lender's Name
o LDMA'Ref. #:'
P.C. Fee$ Permit Fee
Lender's Address
I certify that I have read this application and state that the Issuance Fee /V LDMA P/C#
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction, Investigation Fee Total Fee r J LDMA PeTm:;#�
and hereby authorize representatives of this County to enter.
upoq,the above-mentioned property for inspection p poses.
SEE REVERSE FOR.EXPLANATORY LANGUAGE
D to
nature of Applicant or gent