HomeMy Public PortalAbout5943 AGNES AVE_Building__ R'IRS'COMPENSATION DECLARATION
I ereb af6irm tkat I have a certificate of consent to self
• insure,ora certificafe of Workers' Compensation Insurance, _ APPLICATION FOR BUILDING PERMIT
or a certified copy thereof Sec. 3800, Lab. C.)
Folic NoCtl�o`Z.F�'l &o ' • COUNTY OF LOS ANGELES BUILDING AND SAFETY
y `� Company IlA(1S5f_4 osgcx,.
31 Certified copy is hereby furnished. - FOR APPLICANT TO FILL IN BUILDING
ADDRESS !7
Certified copy is filed-with-the county building inspec- BUILDING
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tion departme``--nt ADDRESS � �\ �/
Date �2�-G1�
�� Applicant -6 t� 7_ C'(S�'���^�tin�/ CITY ZIP ` 1 1 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' 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 Mo- ASSESSOR
hundred.dollars ($100)or less.). TRACT BLOCK' LOT NO. MAP BOOK PAGE PARCEL
TEL. AAVLC USE ZONE MAP n/
I'certify that in the,performonce of the work forwhich'this OWNER LIS NO. 1 NO. V 2 '
permit is issued,1 shall not employ any person in any manner �.� SPECIAL O
so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS V
CITY ZIP
Date'"""' Applicant' .. O
NOTICE TO APPLICANT: If, after 'making this Certificate of ARCHITECT OR TEL.$i DISTRICT GROUP TYPE FIRE PROCE SED BY
ENGINEER V NO: " ~
Exemption, you, should become subject,to the•Workers' `` `'� CONST. / Z 5 U W
Compensation provisions of the Labor'Code, you must forth- ADDRESS '� S� - IVB U �Y/ d
with comply with such provisions or this permit shall be H
TEL. STATISTICAL CLASSIFICATION APT. ONDO: Z
deemed,revoked. .. . . - . —
CONTRACTOR NO. ,
LICENSED CONTRACTORS DECLARATION LIC.- CLA55 NO.— DWELL. UNITS
—
I hereby affirm that 1 am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC- SEWER MAP z
Professions Code,•ond my license is in'f'ull force and effect. CITY CLASS BK PG. IQ I M
SQ.FT NO. OF NO. OFS. CHECK
License Number 42•`11�� Lic.Class SIZE t0 STORIES FAMILIESONE
VALUATION .I a 6 6 0.7 5
Contractor �� 2- Date Z — �' DESCRIPTION OF WORK NEW ; �I"� o o 660.755:
� ADD � I ll�jv
I am exempt under Sec. ALTER � 0 1.25-86
0 $ 234G,8A
B.&P.C. for this reason REPAIR '
Date: 7�ZSCo USE OF O _
EXISTING BLD v. L EMOL
Signature APPLICANT TEL. �1 FINAL # 0 0 0 0 2 3
OWNER-BUILDER DEC RATION (PRINT) NO. `�[f— �' DATE• ' �j
I hereby affirm-that I am exempt from the Contractor's License 0 2 8 U �J 3
ADDRESS FI NA
Low for the following reason (Section 7031.5, Business and �j► 0 90.
Professions Code): FIRES BUILDENT 'NG By f I'
EJI, as owner of the property, or my employees with ADDRESS �7 5( _
wages as their sole compensation,will do the work and t ] !�L!
the structure is not intended or offered for sale(Section LOCALITY ,
7044, Business and Professions Code). MOVING TEL. n
a1, as owner of the property, ant exclusively contracting CONTRACTOR NO. 4.1 Q,3 A
with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). # 0 0 0 - 23
REQUIRED TOTAL SETBACK FROM EXIST. _
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 0 2 6 8 3 9
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. ® 0 2 6�'3 9
(Sec. 3097, Civ. C.). SIDE
m
P.L.
o Lender's Name 01,25-86rC/lJ v LDMA Ref. #
o 264, 33 (f
m - - -- - - P.C. Fee$ Permit Fee - -
Lender's Address
> f, /t�►
r 1 certify.that I have read this application and state that.the Issuance Fee Vw LDA1 P/C#
a above,information is correct. I agree to comply with all County Investigation Fee l
0 ordinances and State laws relating to building construction, Total FeeLDMA Perm. #
(f
and hereby authorize representatives of this County to enter J-
m upuo a above-mentioned property for inspection purposes.
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a 2 �p SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Alwicant or-Agent --Date - -