HomeMy Public PortalAbout4847 1/2, 4855AGNES AVE_Building 7 y o t
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WORKERS COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to Self W APPLICATION FOR BUILDING ` PERMIT
w
insure or a certificate of Workers Compensation Insurance
or a certiiiecoppyy t7h1 (Sec 3800 L ) - COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NO-OV ' rompon"y BUILDING
} Certified copy is hereby furnished a FOR APPLICANT TFILWN `t ADDRESS - 'xi L-:;F
Certified copy Is filed with the-county building inspec" BUILDING -
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}},pan par ment r , e � ADDRESS
v Applicant ' CITY (, e-71. T ZIP4 • LOCALITY C f
F NO OF BLDGS __ NEAREST
C IFI TE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT CROSS ST r '�
,"COMPENSATION INSURANCE 0.4 _ > ASSESSOR
(This section need°not be completed if the permit is for one% TRACT _ BLOCK - LOT NO MAP BOOK PAGE Zel PARCEL 1
hundred dollars ($100)or less ) r TEL
i OWNE r NO � USE ZONE OP
I certify that in the performance of the work for which this �) I A r(%
permits issued I shall not employ any person in any manner ADDRESS �v .. r SPECIAL }
� -� _� CONDITIONS O
y so as to become subject to the Workers Compensation Laws A
r CITY 4�/ ZIP 01400 c_e- - t U
Date Applicant ` ARCHITECT ORt s ix
TEL DISTRICT GROUP TYPE FIRE CESSED BY 4
NOTICE`TO APPLICANT If after making this Certificate of -• ENGINEER- NO CONST ZONE rs
Exemption you should become subject to the Workers ` s%`�(J� t - w
Compensation,provisions of the Labor Code yoty`must forth -+ ADDRESS - -s 4 - r�� N
with comply with such provisions or this permit shall beTEL STATISTICAL CLASSIFICATION APT, CONDO Z
deemed%revoked t � r ti CONTRACTOR C NO Z _
LICENSED CONTRACTORS DECLARATION LIC a : CLASS NO3 DWELL UNITS�L._
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N SEWER MAP i
(commencing with Section 7000)of Division 3 of•the Business LIC T1 . ,
and Professions Code an my It a is in full force and effect _ CITY CLASS I/ BK gf PG VALIDATION ,
SQ FT ,r O OFNO OF CHECK
License Number U Class_ SIZE STORIES FAMILIES ONE
I r - VALUATION 8 a
Contractor /� r Date DESCRIPTION OF WORK NEW ❑ , $
ADD ❑ `
k ❑I am exempt under Sec JALTER ❑� - ,
G� {B&P C for this reason ' REPAIR ❑ $ r
USE OF "^ a
*_A, ate s _ T� EXISTING BLDG � � DEMOL r
` : APPLICANT TEL w
4
Signature (PRINT) O NO Z� FINAL
OWNER BUILDER DECLARATION DATE
w I hereby affirm that I am exempt from the Contractor s License 'r DATE
,
Law for the following reason4(Section 7031 5 Business and, ADDRESS FINA W
Professions Code) r ^ PRESENT + r r .� - + + By
❑ I as owner of the property or my employees with BUILDING
ADDRESS
wages as their sole compensation will do the work and
v w the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code f ^ MOVING TEL - t r a❑ S-
• r CONTRACTOR rN0 :-
s y '' s h`"I as owner of the property am exclusively contracting M
with licensed contractors to construct the project (Sec "" ADDRESS «« 4 - r _)It :'0«g "3
M1 tion 7044 Business and Professions Code ) } ^�( I.
REQUIRED TOTAL SETBACK FROM EXIST tr,
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY� PROP LINE WID H - t „
I hereby affirm that there is a construction lending agency for FRONT f „ , i L.t;i j JTJ
the performance of the work for which this permit,is issued P L
(Sec 3097 Civ C) ' ^ SIDE ,%
- } ^
4 , PL- r e
Lenders Name ¢ CLIT-Il',`_'� � f f*fry_f--
$ t LDMAzRef p
r r P C Fee$ Permit Fee
� Lender s Address
o I certify that I-have read this application and state that the -k, + Issuance Fee �� �D LDMA P/C#
above information is correct I agree to comply with all Countyi Investigation Fee f
8 - l �� �� LDMA Perm tf %
R ordinances and State laws relating to building construction «1 Total Fee
and h eby authors representatives of this County to enter
upon iM above me tioned property for inspectiop purposes r
NAA �f, Tz -Fl SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Applicant or Agent Date
s �
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