HomeMy Public PortalAbout6327 AGNES AVE_Building__ WORKERS COMPENSATION DECLARATION ,
•t hereby
affirm trlIself
insure or a certificate off WokesCompensatnnsuran A PP L I CAT i O N F O R BUILDING PERMIT
or a certifiedcopy thereof (Sec 380Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby`furnished yBUILDING
Policy No Company
FOR APPLICANT TOFILL IN
ADDRESS
❑ Certified copy is filed with the county building mspec BUILDING 'J z
tion department ADDRESS 0 7 y-
Z / 4,-,5-5 LOCALITY l'�� < Gl l a
,a NEAREST f
Date �d t0 0 3 Applc CIT71
Y ZIP CROSS ST r
CERTIFICATE OF EXEMPTION,FROM WORKERS,;' I eVe* N ", NO OF BLDGS ASSESSOR',
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP y�,
hundred dollars ($100)or less ) TRACT BLOCK LOT NOO A 1 NO SPECIAL
L►
I certify that in the performance of the work for which this OWNER A14J, SGO N(�7_4 CONDITIONS ' 1 110.
permit is issued I shall not employ any person in any manner s DISTRICT GROUP TYPE FIRE PROCESSED BY CI
so as to become subject to the Workers Compensation Laws ADDRESS 10 3 Z7 /V eg'S CON ZONE 'U
,3 97 1
Date Applicanted
CITY C.E Cl — ZIP , STAT �LCLASSIF`I ION APT CONDO
NOTICE TO APPLICANT If after making this Certificate of 5 ARCHITECT OR TEL
Exemption you ,should become subject to the Workers ENGINEER Al 0 NO CLASS NO DWELL UNITS L
Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP M CL
= Z
with comply'with such provisions or this permit shall be J �� Z
a Ged 1Z"-4e- CO r NO`1 6 / �/ VALIDATION
deemed revoked CONTRALTO BK PG
' LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS a wr 6.r VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code and my licensee is in full force and effect CITY /1. GAD/ $CLASS �J ` CJ
9(6 3 T 9 Lc Class A6 SQ FT OF OF f CHECK ' ► -
License Number SIZE ,7 O STORIES � ]FAMILIES / ONE
$
Contracd 1°I C -bete /6 ��°�B J DESCRIPTION OF WORK NEW ❑
ADD `
❑ I am exempt under Sec Sea /2 ALTER ❑ FINAL
❑
B 8P C for this reason V �'� REPAIR DATE ,
USE OF By
� O .�.�
INAL
Date EXISTING BLDG � / DEMOL E] Y `
Signature APPLITEL
OWNER-BUILDER DECLARATION _ PRI L'O12MAGNp t
I hereby affirm that I am exempt from the Contractor s License 2 5 8 5 9 A
Law for the following reason'(Section 7031 5 Business and ADDRESS 37a GIJ r GftM/.v0
Professions Code) PRESENT ,
BUILDING z
❑ I as owner of the property or my employees with ADDRESS 4 1 2`a 2 0 9 2 5
wages as their sole compensation will clothe work and Vr nI
the structure is not intended or offered for sale(Section LOCALITY Q ry 0 - 2 0 9}2 5�
7044 Business and Professions Code) MOVING TEL
❑ I as owner of the property am exclusively contracting CONTRACTOR NO I 007-83
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code)
-CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM EXIST y
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 , o
(Sec 3097 Civ C ) SIDE
z
m PL
Lender s Name q,91�
�.✓ P C Fee$ Permit Fee 1
Lender s Address
I certify that I have read this application and state that the Issuance Fee
above information is correct I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction Total Fee C `2 r
and hereby authorize representatives of this County to enter
upon the above-men i d property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
i
Signature of Applicant or Agent Date r Os