HomeMy Public PortalAbout5813 AGNES AVE_Building__ Ia
WOR
j ERS COMPENSATION DECLARATION
r i affirm that I have a certificate of consent self APPLICATION F®R BUILDING PERMIT
"'insure or o certificate of Workers Compensation Insurance
or o cf+rhfied copy thereof (Sec 3800 Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
❑ . Certified copy is hereby furnished t FOR APPLICANT TO FILL IN BUILDING
/?
ADDRESS `J
❑ Certified copy is filed with the county building inspec BUILDING /� ti
tion department ADDRESS . /1
Date Applicant CITY ZIP Q LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT O NOW ON LOT CROSS ST
(This section need not be completed if the permit is for one TRACT OASSESSOR
BLOCK LT NO
hundred dollars ($100)or less ) ,I MAP BOOK PAGE PARCEL
OWNERS-Wk,1J NO T ^ USE NE MAP _�
I certify that In the performance of the work f Ich this NO
permit is issued I shall not employ person I any manner ADDRESS ( 1 PE IAL
so as to become subject to the Wall-r C e sat n Lows CONDITIONS 0
U
Date Applicant CITY 1 T_JJ ZIP 7�V ,
ARCHITECT OR TEL `fir/ '` DIST G75]
UP TYPE FIRE PRO SSED BY U
NOTICE O APPL CANT If after m Ing this C rtificate of GI-�'-tJR)►J �oWii NO -[T �7u7 Exemption you should become subject to the Workers ENGINEER CONST ZONECom ensation rovisions of the Labor Code ou must forth withpcomply wth such provisions or this permit shall be ADDRESS F 1 -,5
deemed revoked pp� TEL STATISTICAL CLASSIFICATION APT C DO to
t CONTRACTOR ►J ^ 1 O1!. O /
LICENSED CONTRACTORS DECLARATION LIC CLASS NO �/ DWELL UNITS—
I
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP
Professions Code and my license Is In full force and effect CITY CLASS BK PG VALIDATION
SQ FT OF OF CHECK #
License Number LIc Class SIZE STZE � STORIES � FAMILIES
MILIES ONE
MA-Sap, r»n VALUATION do
Contractor Date DESCRIPTION OF WORK E�$h NEW ❑ $ 5 /)D� ( - 42G75
❑ I am exempt under Sec 6 n "`^ dd rdfl Icy `�'�
ALTER ❑ v V , 0 a 4 2 Q 7 5
CE
B 8P C for this reasonTSEAOF
r7 7 /�T/Q ❑ $
REPAIR
! DEMOL 1710 9 17-87
Date EXISTING BLDG Pc+lnZI -10 V
Signature APPLICANT TEL
OWNER BUILDER DECLARATION PRINT PSR Qs�15 NO FINAL ZcS
DATE
I hereby affirm that I am exempt from the Contractor s License 6koc-3
��Law for the following reason (Section 7031 5 Business and ADDRESS ca A
Professions Code) PRESENT
BUILDING 8 2 0.9 A
I as owner of the property or my employees with ADDRESS `
wages as their sole compensation will do the work and
the structure Is not Intended or offered for sale(Section LOCALITY # s o • • e
7044 Business and Professions Code) MOVING - TEL JH 4
❑ I as owner of the property am exclusively contracting CONTRACTOR NO t l 1 - 50550
with licensed contractors to construct the project (Sec 4 ��
tion 7044 Business and Professions Code) ADDRESS r t'� 't�4 � rZ ti o 0 5 0 5 5 0 v
CONSTRUCTION LENDING AGENCY SET BACKUIRED YARD HWY TOTAL ROPSET1 } % �4 ,
SET BACK PROP LINE WI � i `a
I hereby affirm that there Is a construction lending agency for FRONT -.A t 10.2W-87
the performance of the work for which this permit Is Issued P L
(Sec 3097 Civ C ) SIDE r
P L
Lender s NameLDMA�n _Lender s AddressP C Fee E Oma/r Permit FeeRef M0j certify that I have read this application and state that the Issuance Fee LDMA P/C M Polo unature
rrect I agree to comply with all County Investigation Feetate ws relating to building construction Total Feeorize epresentatives of this County to enter LDMA Perm N
me Ione property for Inspectionurposes
SEE REVERSEFOR EXPLANATORY LANGUAGE
f Applicant or Agent Dat