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Home My Public Portal About5951 AGNES AVE_Building__ ORKERS' COMPENSATION DECLARATION �— i insure, orhre aafcertif carte of Workers' Comtpensat on eInsuran ent to lf APPLICATION FOR BUILDING PERMIT �a or q 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 ADDRESS Certified copy is filed with-the county building inspec- [BUILDINGtion department. ADDRESSDate Applicant ITY Cl ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT So X NOW ON LOT CROSS ST (This section need not be completed if the permit is for one ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. USE ZONE MAP I certify that in the performance of the work for which this OWNER NO NO. } permit is issued, I shall not employ any person in any manner ADDRESS �j SPECIAL a so as to become subject to the Workers'Compensation Laws. CONDITIONS 0 Date ��U CITY ZIP 0 b , Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If, aft making i Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE P SED BY 0 Exemption, you should become subject to the Workers' CONST. ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS � LLJ with comply with such provisions or this permit shall be TEL. r� deemed revoked. STATISTICAL CLASSIFICAT ON APT. CONDO. (n CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC CLASS NO. D UNITS 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 VALIDATION SQ. FT. NO. OF NO. OF CHECK BK. PG. License Number Lic.Class SIZE ISTORIES FAMILIES ONE O VALUATION Contractor Date DESCRIPTION OF WORK NEW ADD $ , I am exempt under Sec. a ALTER B.&P.C. for this reason REPAIR $ Date: USE OF EXISTING BLDG. DEMOL Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION PRINT NO. DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FI Prof ssions Code): PRES NIT BUILDING 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 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). FROM EXIST. CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK SET BACK PROP. LINE WIDTH 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. (Sec. 3097, Civ. C.). SIDE P .L. Lender's Name m LDMA Ref. # Lender's Address . Fee S Permit Fee _/��.0 tJ , I certify that I have read this application and state that theIssuance Fee L d ��f LDMA P/C# above information is correct. I agree to comply with all County Fee -�11 0 ordinances and State laws relating to building construction, Total Fee e5)i LDMA Perm. # and hereby authorize representatives of this County to enter upon the above-mentioned property f r inspection purposes. ,`o SEE REVERSE FOR EXPLANATORY LANGUAGE OSignature f Applicant or Agent B Date WORKERS COMPENSATION DECLARATIONh-re instireboraafirm certif carte of Worke s Compe of ensation on Insuran ent to selfhere APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY :ohcy No Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING ❑ �Gf ADDRESS ` Certified copy is filed with the county budding inspec BUILDING tion department ADDRESS /y Date Applicant CITY ZIP 9�7� LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS i NO OF BLDGS NEAREST a COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST (This section need not be completed if the permit isforone TRACT BLOCK LOT NO ASSESSOR hundred dollars ($100)or less ) MAP BOOK PAGE PARCEL TEL USE ZNE MAP OP I certify that in the performance of the work for which this OWNER NO - po' NO permit is issued I shall not employ any person in any manner ADDRESS S PECIAL � so as to become subject to the Workers Compensation Laws CONDITIONS C) Date 7� �" Ar 'c CITY ZIP 'I 0_ ARCHITECT TEL NOTICE TOAPPLICANTIf make g this Certificate of ENGINEER Pi 0� DISTRICT ROUP OPT MORE PROCESSED BY r Exemption you should b me subject to the Workers NO Compensation provisions of the Labor Code you must forth ADDRESS 5 toy] with comply with such provisions or this permit shall be TEL STATISTICAL CL SIFI ATION APT I CO UL deemed revoked CONTRACTOR -- NO Z LICENSED CONTRACTORS DECLARATION LIC CLASS NO v DWELL UNITS — 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 L PG/2-6 VALIDATION SQ`FT IYOVSC NO OF NO OF CHECK License Number Lc Class SIZE STORIES FAMILIES ONE q�j g(�f'j; VALUATION Contractor Date DEAR166TION OF WORK NEW D 1:1 $ J �1 r (J �06115A FiI am exempt under Sec ALTER # o e • 0 23 B 8P C for this reason S S REPAIR $ 1 - 40355 1 Date USE OF DEMOL EXISTING BLDG Si nature APPLICANT ` TEL ® • 4 0 3 5 5'0 g OWNER BUILDER DECLARATION PRINT K NO DATEL %_4t1/� 9 0 ]!•.8 I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and ADDRESS S GS r6 FINAL Prof ssions Code) By �V,` z /� BUILDING I as owner of the property or my employees with ADDRESS 4/ ` 'wages as their sole compensation will do the work and ® 0 the structure is not intended or offered for sale(Section [AD LITY t 7044 Business and Professions Code) NG TEL 1 as owner of the property am exclusively contracting RACTOR NO , W with licensed contractors to construct the project (Sec f tion 7044 Business and Professions Code) ESS �! a t ;21 2 1 4 A UIRED TOTAL SETBACK t ti 3 M L CONSTRUCTION LENDING AGENCY BACK YARD HWY PROP LINE WIDTH - ' # e o e e ce'1 I hereby affirm that there is a construction lending agency for NT 4 ( o Q'8 5 2 5 the performance of the work for which this permit is issued + _ �r ,� ' , ; (Sec 3097 Civ C ) E �� V r ��1��s. �� `�y _ �_tar �_1 a l e485250 lender s NameLDMA Ref iLender s Address ee b Permit Fee L I129 88 I certify that I have read this applcation and state that theIssuance Fee /(JLDMA P/C# above information is correct I agree to comply with all County igation Fee t,^ 0 ordinances and State laws relating to building construction Total Fee ✓ 0 LDMA Perm # r Q and hereby authorize representatives of this County to enter ;pAoneabove mentioned property for nspection purposesSEE REVERSE FOR EXPLANATORY LANGUAGE atur of Applicant or Agent Date a U /