HomeMy Public PortalAbout5757 AGNES AVE_Building__ Y � I
WORKERS COMPENSATION DECLARATION r
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ent to sel
insure bor affcertif cote of Worke srtCo`mpens'at on Insurance- APPLICATION FOR' BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C ) n COUNTY OF LOSr,ANGELES r BUILDING AND SAFETY 9
Policy No Company BUILDING &-r7 ' y
rtrfied copy is hereby furnished z a FOR APPLICANT TO FILL IN ADDRESS Ai6-5
Certified copy is filed with the count building mspec BUILDING s
tion department ADDRESS r LOCALITY
]d r NEAREST
Dote 11 �7� IIIicant CITY ZIP CROSS ST
CERTIFICATE OF EXEMPTION OM WORKERS NO'OF BLDGS ASSESSOR
COMPENSATION INSURANCESIZE OF,LOT - NOW ON LOT MAP BOOK PAGE PARCEL S
a USE ZONE MAP
(This section need not be completed if the permit isforone TRACT A BLOCK LOT NO c NO t
hundred dollars ($100)or less ) " T p Y SPECIAL }
' OWNER Z_() r CONDITIONS ti d
I certify that in the performance of the workffor which This s DISTRICT G UP TYPE FIRE PR ESSED BY O
permit is issued I shall not employ any person in any manner ADDRESS J U �-� !I�/ CONST r ZO Ef V
so as to become subject to the Workers Compensation Laws (f o a �" ®C
Date Applicant ` CITY ZIP ` STATISTICAL CLASSIFICATION APT �ONIDO O
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL w
Exemption you should become subject to the Workers ENGINEER NO - i CL
CLASS NO DWELL UNITS , JU
Compensation provisions of the Labor Code you must forth ADDRESS y - SEWER MAP N
with comply with such provisions or this permit shall be TEL
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deemed revoked VALIDATION CONTRACTOR t O t��� " BK PG 4
I , LICENSED CONTRACTORS DECLARATION LIC r
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION
(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 11 -
SQ FT NO OF NO OF CHECK
Lcense,NumberLIM, Lc`Class .. SIZE STORIES r FAMILIES ONE
��1 r)j/
'/-40 1 6IK 1604 cite vt� DESCRIPTION OF WORK Q NEW ❑ $
/
Contractor ' F
I am exempt under Sec ADD Ell�� ALTER ❑ FINA
B&P C for this reason L t E� �� 0� DAT f ,
REPAIR
,' USE OF FIN >� r
Date t EXISTING BLD 5 CL/QS's OL ❑ j B
r
� Signatur r _ APPLICANT V � O
TE
UILDER DECLARATION PRINT
I hereby affirm that I am exempt from the Contractor s License -2 5 2 4, 1 A
Law for the following reason (Section 7031 5 Business and ADDRESS ✓C , .0l h T r
Professions Code) 4 x s° _
❑
I as owner" y n Y # o • o • 0 1
of the property o my employees with BUILDING
,
wages as their sole co 'm
ensation will do the work and
the structure is not intended or offered for sale(Section LOCALITY ° ° 6 6 3 ^' °
7044 Business and Professions Code) » MOVING TEL
CONTRACTOR NO 6 a 6 3_xr,
as owner of the property am exclusively contracting I
jwith licensed contractors to construct the project (Seca 1 3—8 6
^tion 7044 Business and Professions Code) -
" REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH
I hereby affirm that There is a construction lending agency for FRONT
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the performance of the work for which this permit is issued P L ,
(Sec 3097 Civ C ) ` SIDE r r 1 G +
Lender s Name `
Lender s Address J PC Fee$ Permit Fee
I certify that I have read this application and state that the Issuance Fee
a above information is correct I agree to comply with all County Investigation Fee
4ordi ices d State laws re ting to building construction 3 "_ i "* t,hereby ae repres ntatives of this County to enterTotal Fee n t e mentioned roperty for inspectto urposes
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SEE REVERSE FOR EXPLANATORY LANGUAGE
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Applicant or Agent Date
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