HomeMy Public PortalAbout4846AGNES AVE_Building (5)1
ORKERS, COMPENSATION DECLARATION
ereby affirm that I have a certificate of consent to self
x APPLICATION FOR BUILDING P E RM I TisureoracertificateofWorkersCompensationInsurance
o .a mersfied copy thereof (Sec 3800 Lob C)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poll y f4aAma—Company
BUILDINGRCertifiedcopyisherebyfurnishedFORAPPLICANTTOFILLINADDRESS
Certified copy is filed with the county building inspec BUILDING
Tion department ADDRESS O
Date4 - Applicant
CITY ZIP LOCALITY
1
NO OF BLDGS NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT S NOW ON LOT CROSS ST
COMPENSATION INSURANCErThissectionneednotbecompletedifthepermitisforoneTRACTBLOCKLOTNOMAPBOORKPAGEPARCEL
hundred dollars ($100)or less ) TEL
OWNER NO USE ZONE MAP Er
I certify that in the performance of the work for which this
NO
r
permit is issued I shall not employ any person in any manner ADDRESS
SPECIAL r o.
x CONDITIONS OsoastobecomesubjecttotheWorkersCompensationLawsC)
CITY Q-414 ZIP
a
Date Applicant ARCHITECT OR TEL r DISTRICT OUP TYPE FIRE PROCESSED BY
V
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO CONST ZONE
Exemption you should become subject to the Workers AA y
Compensation provisions of the Labor Code you must forth ADDRESS 3 J N
with comply with such provisions or this permit shall be TEL 243 -7 STATISTICAL CLASSIFICATION APT CONDO Z
deemed revoked,, CONTRACTOR
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITSLICENSED
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS k4rl omie 4,Lp NO SAC IZ
SEWER MAP
commencing with Section 7000)of Division 3 of the Business LIC
and Professions Code and my license is in full force and effect
CITY CLASS
BK PG VALIDATION
SQFT NO OF NO OF CHECK
License Number Lic Class_ SIZE STORIES FAMILIES ONE
VALUATION 4
Contractor kerb /{'J Date 7 DESCRIPTION OF WORK NEW
j
ADD
I am exempt under Sec
ALTER
popt
B&P C for this reason
i
REPAIR
Date USE OF
EXISTING BLDG DEMOL
Signature "'O APPLICANT TEL ! FINAL
OWNR B YIDERDECLARATION
PRINT) e' Les NO O
1 hereby affirm that I am exempt from the Contractor s License
ADDRESS 2
DATE 1117#T
Law for the following reason (Section 7031 5 Business and FI
Professions Code) PRESENT Y K= A
BUILDING t r AM T
a 1 as owner of the property or my employees with ADDRESS t T
s I j S e4 ``tom :,
wages as their sole compensation wil I do the work and 'k)
14 r 0307; 209 29
the structure is not intended or offered for sale(Section LOCALITY
1 1 7044 Business and Professions Code) MOVING TEL t l r
CONTRACTOR NO
I as owner of the property am exclusively contracting L If A 209.25
with licensed contractors to construct the project (Sec r y"
AL
1ntion7044BusinessandProfessionsCode )
ADDRESS
a ,- _3 a
y +
y"i V"• #
CHRK 207 29
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH ru trCI
I hereby affirm that there is a construction lending agency for FRONT
J
411tt1'iVG
the performance of the work for which this permit is issued P L
Sec 3097 Civ C) ] SIDE t
Lender s Name
Lta
NAH
t
y
P L - Onr -0001 7Mf 689
e P C Fee S P m t fee299
LDMA Ref # SVut
8V
1 AI l 11 Fq
Lender s Address
y
K
c I certify that I'Rove read this application and state that the Iss o ce Fee d LDMA P/C#
8 above information is correct I agree to comply with all County I e t gat on Fee
ordinances and State jaws relating to building construction Total Fe V LDMA Pe m #
and hereby authorize representatives of this County to enter
upon the above mention erty for inspection purposes r
SEE REVERSE FOR EXPLANATORY LANGUAGE
e
g of o App a t o Age t Date
a+
S