HomeMy Public PortalAbout5742 AGNES AVE_Building__ frQ- kERS'COMPENSATION DECLARATION "
i surificate-of consent to
afcertit carte of Worke sve a rlCompensation Insurance, APPLICATION,• F FOR BUILDING PERMIT
O BU LD NG PERM
or a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
copy y FOR APPLICANT,TO FILL IN BUILDING
Certified co is hereby furnished. ADDRESS L aC
Certified copy is filed with the county building inspec- BUILDING f/� y�s
tion.department. ADDRESS 7 rT[sr
Date Applicant CITY �j/� i ZIP / /� LOCALITY i
CERTIFICATE OF EXEMPTION FROM WORKERS' ryO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT 0 .l 0 NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for oneCK ASSESSOR
hundred dollars ($100)or less.) TRACT BLOLOT NO. MAP BOOK PAGE PARCEL
A� ys� TE USE ZONE MAP
I certify that in the performance of the work for which this OWNER C`J'!iG /`I'?T NO. 3 NO. y�
permit is issued, I shall not employ any person in'any manner C �/ �J� SPECIAL
so as.to beco e s bject to the Workers'Compensation Laws. ADDRESS v �T�/►/ -1414.510W— �/ I CONDITIONS O
Date Applicant CITY ! `/ ZIP f if
NOTICE A LICANT: If, after mARCHITECT O TEL
akin this Certificate of DISTRICT- GROUP. TYPE FIRE __ PRO SSED BY O
CONST./ E /
Exemption, you should become subject to' ENGINEER NO. ZON
the Workers' V ' U
Compensation provisions of the Labor'Code,you must forth-
.permit shall be ADDRESS
With comply with such provisions or thisdeemed revoked. TEL. STATISTICAL CLASSIFICATION APT. CO O. ;ECONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS_NO. DWELL UNITS
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. NO. OF NO. OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
P-s�i►« �- NEW O VALUATION _
Contractor Date DESCRIPTION OF WORK ,
p ADD $
O 100
I am exempt under Sec.
/� ALTER
B.&P.C. for this reason /�a</j D(I df tw G� REPAIR ❑ $
Date- USE OF _ DEMOL
EXISTING BLDG. ❑
Signature APPLICANT TEL. FINAL /`
OWNER-BUILDER DECLARATION PRINT epB(.L Sei N0�8S-7"J3 DATE -
I hereby affirm that I am exempt from the Contractor's License Jr '4 A .
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL' 0 0 0 0 ,0
Professions Code): PRESENT BY� �'-
BUILDING r.
I, as owner of the property, or my employees with ADDRESS 1 9 -
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY / 0 0 9 9 8 8
-7044, Business and Professions Code). MOVING " ' TEL. /
I, as owner of the property, am exclusively contracting
CONTRACTOR NO. O 72 8-86
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code). ADDRESS /
CONSTRUCTION LENDING AGENCY REQUIRED--
SET BACK YARD HWY TOTAL SETBACK FROM_ _ J
I hereby affirm that there is a construction lending agency for FRONT PROP. LINE WIDTH
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
Lender's Name i
m LDMA Ref. # i
P.C. Fee$ - - Permit Fee - 1 ' -
Lender's Address
I certify '
w h . he
�. Y that I.have read this application and state that t
Issuance Fee .�� kLDA P/C-#
above information is correct. I agree to comply with all County Investigation Fee
w ordinances and State laws relating to building construction;
I Total Fee t LDMA Perm. #
v and hereby authorize representatives of this County to enter
upon the
�above-mentioned
property for inspection pu pose .
SEE REVERSE FOR EXPLANATORY LANGUAGE
SignaturoKof Applicant or Agent #Date OO