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6009 AGNES AVE_Building__
r 9 WORKERS COMPENSATION DECLARATION ' r , I I' I,.hereby affirmthat I have a certificate of consent to self insure or a certificate of Workers Compenstion InsUraNice ar APPLICATI®N � F®R ILDING �PERIVIIT 4 a 1ertified copy thereof (Sec 3800 Lab C ) I t COUNTY OF LOS ANGELE� BUILDING AND SAFETY �^ Policy No Company 1 ' El, Certified copy is hereby furnishedFOR APPLICANT TO FILL; IN ADDRESS Certified copy is filed with the county building inspec BUILDING - / hon department r ADDRESS /,�fS A)S ` LOCALITY (% NEAREST Date Applicant - CITY r' C,7v ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS If INO OF BLDGS ASSESSOR 'COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK r PAGE IWPARCEL (This section need not be completed if the permit is for one USE ZONE FSP P , hundred'`dollors ($100)or less ) TRACT BLOCK LOT NO © /'� �eTEL1 � CIAL aI certify that in the'performance of the work for which this OWNER NO $ �� a NDITIONS } O DISTRICT GROUP TYPE FIRE P CES BY ,permit is issued I shall not employ any person in any manner a y U so as to become subject to the Workers Compensation Laws ADDRESS ��,�/ s �r e CONST Z Date } 1 Applicant--I CITY ZIP STATISTICAL CLASSIJF Cq�ION APT CONDO s ARCHITECT OR TEL V NOTICE TO APPLICANT If after makings this Certificate of ENGINEER NO Lu Exemption 'you should become subject to the Workers CLASS NO DWELL UNITS Compensation provisions of the Labor Code you must forth y with comply with tsuch provisions or this permit shall be ADDRESS SEWER MAP Z_ F deemed revoked _ _ TEL CONTRACTORNO ( BK PG VALIDATION LICENSED CONTRACTORS DECLARATION UC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO Y VALUATION (commencing with Section 7000)of Division 3 of the Business and t LIC Professions Code and my license is in full force and effect { CITY CLASS $ i SQ FT NO OF NO OF CHECK t License Number Lic Class SIZE STORIES FAMILIES / ONE t DESCRIPTION OF WORK ( 1 A NEW Contractor Date ❑ 0 1 am exempt from the licensing requirements as I am a ADD licensed architect or a registered professional engineer ALTER FINAL ` acting in my professional capacity, (Section 7051 REPAIR DATE 2— Business and Professions Code)' USE OF FINAL EXISTING BLDG s DEMOL Lic or^Reg No / Date APPLICANT / TEL 8y v OWNER BUILDER DECLARATIONI (PRINT) /�! NO�$S I hereby affirm that I am exempt from the Contractor s License /� Y Law for the following reason (Section 7031 5 Business and ADDRESS,,(009 'N/e' !V` Ire_ I17,50 Professions Code) _ PR SE T ® ' BUILDING / ^ ,Q , � I as owner of the property or my employees with ADDRESS 4-© /4';,!1 ` ' "v'7 7�/78d M wages as their sole compensation will do the work and 4/78J the structure is not intended or offered for sale (Section LOCALITY /C r1 L.: Cil 7044 Business and Professions Code) Lt MOVING TEL 7 p ❑ CONTRACTOR NO� J / I as owner of the property am exclusively contracting with licensed contractors to construct the project (Sec [ADDRESS t $� • e • o • tion 7044 Business and Professions Code) r QUIRED TOTAL SETBACK FROM EXIST 7 9 0 CONSTRUCTION LENDING AGENCY BACK YARD HWY PROP LINE WIDTH r2 • o' I hereby affirm that there is a construction lending agency for ONT J - the performance of the work for which this permit is issued L i o 0 01'7 9 O 0 m (Sec 3097 Civ C ) t DE f q Lender s Name 20 '7-87 Fee$ Permit FeeLender s Address W I certify that I have read this application and state that the Issuance Feeabove information is correct I agree to comply with all County stigation Fee ordinances and State laws relatmg to building construction Total Fee u and hereby authorize representatives of this County to enter upon the abo✓e mention d pr petty for inspection purposes Q -7 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant oror Agent— r Date C�' ��3 2 5 M B E _ l '