HomeMy Public PortalAbout6024 AGNES AVE_Building__ ~ WORPERS COMPENSATION DECLARATION L s LL
• I -hereby
arrt
consent self
intsye ordertifcate of WorkesCompensation Insurance APPLICATION F O RBUILDING PERMIT
or o certifi�ccopy thereof (Sec 380Lab C )
t
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 BUILDING
tion department ADDRESS X � <
Date Applicant , " CITY CL I ZIPInn A C�rI LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS O OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT WON LOT CROSS ST G(/I
(This section need not be completed if the permit is for one _ ASSESSOR
hundred dollars ($100)or less ) TRACT BLOCK L T NO MAP BOOK PAGE PARCEL
TEL G USE NE MAP '
I certify that in the performance of the work for whch,this 6 � w ` ' moo?3a NO
permit Is issued I shall not employ any person in any manner /�/y►� / SPECIAL
so as to become subject to the Work Compe tign La s s ESS "b�� " ` �S �`t ( CONDITIONS
r 1
Date Applcan ARCHITECT OR 'f ( CA ZIP TEL /7 r -6
NOTICE TO APPLICANT If after ma ing this Certificate of DISTRICT GR UP TYPE FIRE PROCESSED BY O
Exemption you should become s lett to the Workers ENGINEER NO p-. e/ J CONST / E U
V\CCCIJUU/IIX� V +
Compensation provisions of the Labor Code you must forth _
with comply with such provisions or this permit shall be ADDRESS TEL - STATISTICAL C IFI ATION APT DO Cn
deemed revoked u CONTRACTOR N Z
LICENSED CONTRACTORS DECLARATION IC CLASS NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O
(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 `
SO FT NO OF NO OF CHECK BK PG
License Number Lc Class SIZE ' STORIES FAMILIES ONE
VALU 10
> RIPTION OF WORK NEW E:] /Y3(� r
Contractor Date ( J
ti
F-1I am exempt under Sec T � DD
ALTER
B 8P C for this reason Date r fE F ` REPAIR $ 92s13A
NG BLDG DEMOL ❑
Signature APPLICANT TEL „^_ # o-o o • o
FINAL
OWNER BUILDER DECLARATION PRINT NO DATE �� ✓ o e 2 8 5 0 '
I hereby affirm that I am exempt from the Contractor s License
Low for the following reason (Section 7031 5 Business and ADDRESS FINAL 2 a 5
Pr essions Code) By /fY� ° • °
00
BUILDING
t I as owner of the property or my employees with ADDRESS Z.A19-,88
wages as their sole compensation will do the work and ' r
the structure is not intended or offered for sale(Section [ADDR
ITY
7044 Business and Professions Code) NG TEL f
RACTOR NO
I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec
tion 7044 Business and Professions Code) ESS
CONSTRUCTION LENDING AGENCY UBACKIRED YARD HWY TOTAL ETPROPROALINE WIDTH 1 #f 1� Vi
I hereby affirm that there is a construction lending agency for NT
the performance of the work for which this permit is issued
(Sec 3097 Civ C )
t
Lender s Name
w ' ` LDMA Ref # s 4 F
Lender s Address ee S Permit FeeI certify that I have read this application and state that the Issuance Fee (f V LDMA P/C#
oabove information is correct I agree tocomply with all County igation Feeordinances and State jaws relating to building constructionr _ _ Total Fee lJ LDMA Perm #
$ and here y authorize representatives of this County to enter
� p Th bove mention2dMfnspection purposes
3, S_-
m SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date