HomeMy Public PortalAbout4812 AGNES AVE_Building_10/5/1992_Enclosed carport RKERS'COMPENSATION DECLARATION "
T APPLICATION FOR. BUILDING PERMIT,
7 I hereby affirm that I have a certificate of consent to self
insure oroa certificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lab C ) t �� COUNTY OF LOS ANGELES BUILDING AND SAFETY a
Policy No t Company s
r f . Y f `4BUILDING
copy is hereby furnished g, FOR APPLICANT TO FILL IN ADDRESS - SJ-
Certified `t
❑ Certified copy is filed with the county building+nspecBUILDING L/
tion department ADDRE�SSS' / /� j, S� Q/
CITYN 0-1114 Q C,ll zip // L J,1D LocAurr
Date � Applicant NO OF BLDGS NEAREST / '
e CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT " NOW ON LOT r CROSS ST i-ermuzft
COMPENSATION INSURANCEO/�D ASSESSOR
(This section need not be completed of the permit is for one TRACT 970 BLOCK ' LOT NO MAP BOOK 1 PAGE PARCELt
hundred dollars,($100)or less ) ay /� din/� TEL
/� � USE ZONE ac OP r s
I certify that in the performance of the work for which this r' + SPECIAL r a
permit is issued I shall not employrany person in any manner ADDRESS CONDITIONS "
so as to become subject to the Workers Compensation Laws 6/� � ..ZIP f�/� � O
/�_ /� CITY ( [
Date Applicant _o ARCHITECT OR TEL ,.DISTRICT J,GROUP TYPE FIRE PR CESSED BYONOTICE O PPLICANT If after making this Certificate of ENGINEER NO Dn CO ST ZONE U
Exemption you should become subject to the Workers { r A' ^7 " +
Compensation provisions of the Labor Code' you must forth ADDRESS r dl� + J a
with comply with such provisions or this perm+t+,shall be c TEL STATISTICAL CLASSIFICATION APT CONDO an
deemed revoked „t= CONTRACTOR NO .. . Z
t LICENSED CONTRACTORS DECLARATION t LIC CLASS NO��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
a LIC" SEWER MAP
and Profession's Code and my license is in full force and effect CITYa I CLASS BK � PG VALIDATION
License Number Lic Class ST OF FA OF 't CHECK
*" STORIES � FAMILIES ONE
" ti - VALUATION S `F 1'j' I' O
Contractor ^ a ' Date ' DESCRIPTION OF WOR-- A N e } * NEW ❑ $ ? +� 0 r
❑I am exempt under Sec v " m 8 ,s fIr ADD J
v rK ALTER
B&P C for this reason Y4_ S. a « REPAIR $ '
USE OF r
I d Date, EXISTING BLDG f `"' DEMOL ❑ +
Signature t APPLICANT TEL py �r
g OWNER BUILDER DECLARATION (PRINT)A(f WO NO �s0 FINAL �)
I hereby affirm that I am exempt from the Contractor s License /^ f DATE S 4
« L'aw for-the following reason (Section 7031 5 Business and ADDRESS l+ S .�� � V 60fo t` pl s +
Professions Code) _ PRESENT- w t"
Ef �C BUILDING
I as owner of the property or myemployeesywith+ ADDRESS V V
wages as their sole compensation will do the work and •- - w •-- +-� r - raw "
the structure is not intended or offered for so'e(Section [AOD
ALITY w
7044 Business and Professions Code )_-,- VING 7 1 TEL
TRACTOR NO
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec RESS
tione7044 Business and Professions Code r f^
CONSTRUCTION LENDING AGENCY ) QUIRED TOTAL SETBACK FROM "EX'S
T BACK . YARD HWYy a PROP LINE WIDT ti
I hereby affirm that there is a const uction lending agency for ONT
the performance of the work for which this permit is issued L o(Sec 3097 Crv C ) r DEwL o of 3Lender s Name yLDMA Ref #Fee$ Permn Fee
t� Lender s Address -
o I certify that I have read this application and state that the r Issuance Fee a LDMA P/C
8 above information is correct 1 agree to comply with all County Invesr gc tion Fee , ^
R ordinances and State jaws relating to building construction + r i Total Fee LDMA Perm #
and hereby authorize representatives of this County to enter
upon he above me 1io cl roperty for inspection urp ses
f e
(,ll ^SEE REVERSE FOR EXPLANATORY LANGUAGE + M1 c
Signature of Applicant or Agent f 160te