HomeMy Public PortalAbout5746 AGNES AVE_Building__ .IIIIIii, -WORKERS' COMPENSATION DECLARATION
I.Hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or.a certificate of Workers' Compensation Insurance,
a a certified copy.thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING 5
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS - S
❑ Certified copy is filed with the county building inspec- BUILDING� _ \
tion department. ADDRESS
Date Applicant CITY y ZIP ;7LOCALITY
O. OF BLDGS. NEAREST ✓
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 527X Q NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL.
OWNER NO. USE ZONE MAP
I certify that in the performance of the work for which this ___;71
/ NO.
CIAL
permit is issued, I shall not employ any PersAn in any/manner ADDRESS / �� ' CONDITIONS
so as to become sub'ect to the Workers' Cid ss on Laws. __— U
�- _C( / ! �� CITY z- ZIP U
,VDate�' ' ' licant 6.'' ARCHITECT OR T L Z DISTRICT GROUP TYPE FIRE ;PRCESSED BY O
NOTICE TO APPLICANT: If, after making/this Certificate of ENGINEER NO. �/' CONST. ZQNE F—
Exemption, you should become subject to the Workers' x_77
Compensation provisions of the Labor Code, you must forth- ADDRESS i'� �� �! Z ✓�
with comply with such provisions or this STATISTICAL CLASS�ON APT. CONDO. Z
p y p permit shall be TEL.
deemed revoked. CONTRACTOR —+ NO. —
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 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 LIC. T
and Professions Code,and my license is in full force and effect. CITY CLASS BK G PG �� VALIDATION
SQ. NO. OF NO. OF CHECK
License Number Lic. Class SIZ TORIES IFAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK 'Ci^ NE
ADD
ElI am exempt under Sec. ��7 ALTER
B.&P.C. for this reason v11,
REPAIR ❑ /
Date: USE OF DEMOL ❑
EXISTING BLDG. -� ✓
Signature APPLICANT TEL' FINAL
(PRINT) NO f
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT BY
❑ I, as owner of theproperty, or m em to employees with BUILDING
Y P Y ADDRESS 1
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale(Section LOCALITY
ANT.4
7044, Business and Professions Code.) MOVING TEL.
"
I, as owner of the property, am exclusively contracting ,CONTRACTOR NO. -+3,7rJ--ma�yy 7 91a3.;r 7
with licensed contractors to construct the project (Sec- ADDRESS 1 ITEM
tion 7044, Business and Professions Code.) .+
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK WARD HWY PROP. LINE WIDTH T%k 913_87
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. CWV1 913.<Jai,
(Sec. 3097, Civ. C.). SIDE
t
Lender's Name
, LDMA Ref. #
� . a S'P.C. Fee$ Permit Fee 3
�¢ Lender's Address J ILMI-0101 10J/ 918-0 '
O 1 certify that I have read this application and state that the C� ) , I once Fee O ^ LDMA P/C# , 51309 1 AM11:50
above information is correct. I agree to comply with all County Investigation Fee
8 ordinances and State laws relating to building construction, -e / 0 7 ,7, LDMA Perm. #
c and hereby authorize repre entotives of this County to enter
m upon bo -mentio e property for inspection purposes.
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SEE REVERSE FOR EXPLANATORY NGUAGE 9/ '�
Signature of Applicant or Agent a /