HomeMy Public PortalAbout5752 AGNES AVE_Building__ WORKERS' COMPENSATION DECLARATION y ::•:.
hereby affirm that I have certificate of consent to Self APPLICATION' FOR BUILDING P E RM I T
insure, or a certificate of Workers' Compensation Insurance,
or-a 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 J
ADDRESS oL
Certified copy is filed with the county building inspec- BUILDING
'tion department. ADDRESS 00 nn
lr J
1'
Ddte �� Applicant CITYV ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM W RKERS' - 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
T NO.
.hundred dollars ($100)or less.) � TRACT BLOCK LOMAP BOOK PAGE PARCELTEL- '
��}}tt��yy ii USE ZONE MAP
I certify that in the performance of.the work for which this OWNER % ( r NO L0(p 30/ /n/ NO.
permit is issued, I shaWnot employ any person in any manner G �2 ,p ti(�/ SPECIAL
so as to become subject to the Workers'Compensation laws. ADDRESS J ��/ I` CONDITIONS
U
CITYZIP- -
Date Applicant
NOTICE TO APPLICANT: If, after mARCHITECT OR TEL.
making this Certificate of DISTRICT, OUP.° TYPE .• FIRE. PR SED BY
Exemption, you should become subject to the Workers' ENGINEER NO. CONST.' ZONEU
Compensation provisions of the Labor Code; you must forth- (S �. �
ADDRESS
with comply with .such provisions or this permit shall be` TEH
deemed,revoked. CONTRACTORS w -C � N �6 f1 STATISTICAL CLASSIFICATION APT. NDO. �+
V
LICENSED CONTRACTORS DECLARATION LIC,-, q CLASS No. Z1 DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS' S, 'Sar) �l NO: � 0 C_ MEW
(commencing with Section 7000)of Division 3 of the Business and LIC. = - SEWER MAP
Professions Code, and my license is in full force and effect. CITY i CLASS BK PG VALIDATION
R /��I SQ. FT. NO. OF NO. OF CHECK
License Numbers -' c.Class / SIZE STOR S FAMILIES ONE
1 (�,� e�J
VALUATION
Nj
^V .'LGJ ^T r (i DESCRIPTION OF WORK - NEW ❑ $
Contractor- Date ❑ �Q
ADD _
am exempt under Sec. ` ALTER 55 ❑
B.&P.C. for this reason REPAIR ❑ a 4-
Date: DEMOL
USE OF
EXISTING BLDG. ❑
Signature APPLICANTTEL FINAL
OWNER-BUILDER DECLARATION PRINT)��� NO�
hereby affirm that I am exempt from the Contractor's License e `
Law for the following reason (Section 7031.5, Business and ADDRESS v1Cv Lh� FINA
Professions Code): PRESENT By
BUILDING
I, as owner of the property, or my employees with ADDRESS A
�r
wages as their sole compensation,will do the work and LOCALITY �C9.4
the structure is not intended or offered for sale Section
7044, Business and Professions Code). (' MOVING TEL'. e) '
ff
❑ NTRACTOR NO
CO . r ///
I, as owner of the property, am exclusively contracting Lv% f�,•� �'4 7 0,3 A
with'licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). #:0 0 0 0 0.�
REQUIREDTOTAL,SETBACK FROM.
CONSTRUCTION LENDING AGENCY SET BACK YARD" HWY- PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT o' 0 4Q Q
the performance of the work for which this permit is issued - P.L. - -
(Sec. 3097, Civ. C.). SIDE _
o
P. - _ .. 4 8,,0 0
_ v
Lender's Name L L
m - -- P.C:Fee$' - - Permit Fee LDMA Ref. # _ - _ ,O 6,.0.3 z 8 6
Lender's Address
w -
I certify that I have read this application and state that the Issuance Fee LDMA P/C'# a
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State-laws relating to building.construction, Total Fee LDMA Perm. # `
u and hereby authorize representatives of this County to enter
upon thea ove-mentionrop ty for inspection purposes
a
-56 SEE REVERSE FOR EXPLANATORY LANGUAGE ?
a
•Signature of plicant or AgentDate - ---- - =- --^- - - "- - - - - - -