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HomeMy Public PortalAbout4835AGNES AVE_Building (10) WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self A p P I CATI O N F O R M I L D I N G PERMIT Aisure, or'a certificate of Workers'Comp ion Insurance, or certif' d copy thereof (Sec. 3800, ✓t COUNTY OF LOS ANGEL "S BUILDING AND SAFETY No. a Certi Ted o y is urnished. 'f BUILDING 7 FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county b ilding inspec- BUILDING �65 / � --�— t Tion de arime� I ADDRESS s /v � LOCALITY /lr���/ A NEAREST Date l/ vv 111///FFF���pplicant CITY ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM'WORKERS' NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK A_GE PARCEL (This section need not be completed if the permit is for one A0/JE MAP hundred dollars ($100)or less.) TRACT BLOCK LOT NO. / No. A.s ? TEL. /4 ,, y� SPECIAL I certify that in the performance of the work for which this OWNE / /�� it/�cr NO.G�/ 1 v CONDITIONS 0 permit is issued, I shall not employ any person in any manner t'> // /i /�� ISJ,.,i T OUP TYPE FIRE P CE ED BY U ADDRES b /�/ 6cl CONST. • ZONE so as to become subject to the Workers'Compensation Laws. CITY �`� ZIP Date Applicant STATISTIC CLASSIFICATION APT. CONDO. NOTICE TO APPLICANT: If, after making this Certificate of ARC ITECT R TEL` U Exemption, you should become 'subject to the Workers' ENGINEER N `V,J Ci{ SS N DWELL. UNITS Compensdtion provisions of the Labor Code, you must forth- ADDRESV l ) SEWER MAP with comply with such provisions or this permit shall be deemed revoked. CONTRACT k6u's TEL. L BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION I" LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, a d my license is in full force and effect. CITY CLAS $ SQ. FT NO. OF NO: OF CHECK j Licen N mber Lic.Class SIZE. lO STORIES FAMILIES ONE f �( $ Cont a L(/ u / DESCRIPTION OF WORKNEW % ❑ I am-exempt from the licensing requirements as Iam a ADD licensed architect or a registered professional engineer CGn ALTER ❑ FINAL acting in my professional capacity (Section 7051, C® Q5 o REPAIR ❑ DATE I `F� Business and Professions Code). USE OF f EXISTING BLD DEMOL ❑ FINAL �� 6,y Lic.or Reg.No. Date APP(PR NT) NNT [j- OWNER-BUILDER DECLARATION ,�J z I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENI ❑ BUILDING _." 2 0 0 5,54 4 I, as owner of the property, or my employees with ADDRESS .wages as their sole compensation, will do the work and a.o+0 5,,�4 4 x the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). kADDR TEL. 10,29.-8 1 ❑ I, as owner of the property, am exclusively contracting OR NO. with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued 1 7 4,5 A (Sec. 3097, Civ. C.)Lender's Name # oto 0 0LL0/ Permit Fee / 2`0 1'O U Q Q Lender's Address w I certify that I have read this application and state that the Issuance Fee � 0:0 1 0&0 O aabove information is correct. I agree to comply with all County Investigation Fee $ ordinances and State'I s relating to building construction, Toral 1`4 D �U 1 .0,29-81 and here a rize re resentatives of this County to enter / < upon ih abov nti ed property for inspection purposes.' a V (� SEE REVERSE FOR EXPLANATORY LANGUAGE 0 ©s -Signature of Applicant or nt Date _ /