HomeMy Public PortalAbout4847 3/8, 4853AGNES AVE_Building (2) � F
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WORKERS COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure or a certificate of Workers Compensation Insurance
I or a certified copy t reof (Sec 3800 Lab C) + ``s
p� �� r -. w COUNTY OF LOS ANGELES .ria+« ., , BUILDINGrAND SAFE
Policy 4—,�� CompanyBU 1
❑ LDING
Certified copy is hereby furnished + FOR APPLI ANT TO FILL IN ' ADDRESS
Certified copy is filed with the county.,budding mspec BUILDING G
- PPtttiioolln department %r r ADDRESS Q
Date jrcanT CIN ` - ZIP LOCALITY
,r r NO OF BLDGS NEAREST _
CERTIFICATE F EXEMPTION FROM WORKERS ' - SIZE OF LOT" NOW ON LOT CROSS ST
COMPENSATION INSURANCE_ �j-/_ ASSESSOR �6-4 ° PAGE f O.1Q��
(This section need not be completed if the permit is for one TRACK Q S� BLOCK LOT NO MAP BOOK , fl / d"� PARCEL D
hundred dollars ($100)or less ) . TEL3611
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+ e S t -. OWNER NO JJ/ 7.1,`° USE ,EKY NO r
I certify that in the performance of the work for which thisze, SPECT « e.i - }
permit is issued I shall not employ any person in any manner r ADDRESS 7 CONDITIONS a a'
so as to become subject to the Workers Compensation Laws �!CJ/+ - f QE OV
° 6 CITY ZIP �+ ,
Date Applicant 5- ARCHITECT OR - TEL a'
NOTICEJO APPLICANT If after making this Certificate of ENGINEERLu
NO s DISTRICT GROUP CONST ' ZONE PROCESSED BY O
Exemption you should become subject to the Workers �j� �/ *' - T - ° Lu
Compensation provisions of the Labor Code you must forth r ADDRESS r � , .C4--
N
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO Z
deemed revoked r y ; r CONTRACTO NO + / r —
LICENSED CONTRACTORS DECLARATION ' LIC tL CLASS NO DWELL UNITS
-:!L
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N 7 SEWER MAP J
(commencing with Section 7000)of Division 3 of the Business x LI }
and Professions Code and my lic rise rs in full force and effect CITY CLASS BK PGJ VALIDATION «
SQ FT NO OF NO OF / CHECK t - �.
License Numberfo(v '"` Lle Class , 51ZE STORIES FAMILIES ONE
; $z.�'� - VALUATION *
eke < r
Contractor Date (J, DESCRIPTION OF WORK , i NEW ❑ -
_ t M �t
ADD ❑r $ , v a
❑I am exempt under Sec r ALTER ❑ - - '
B&P C for this reason « ' $ t�
w +
U -f
Date SE EXISREPAIR ❑
OF
TING BLDG - z/ DEMOL t r r Y
Signature ,y
APPLICANT- ®NNO 15,1'77
5 �� FINA
OWNER BUILDER DECLARATION PRINT
DAT
I hereby affirm that I am exempt from the Contractorts LicenseV1
Law for the following reason (Section 7031 5 Business and ADDRESS FINA '4 Z
Professions Code) z a K PRE ENT - t _ BY-. x
❑ I as owner of the property or m employees with BUILDING r
„ P P Y YADDRESS
wages as their sole compensation will do the work and - - - �-
t
the structu-re is not intended or offered for sale(Section cr LOCALITYpop
41 9111
• i r
7044 Business and Professions Code ) MOVING- w _ TEL
E] CONTRACTOR NO I as owner of The property am exclusively contracting r
with licensed contractors to construct theroI ect (Sec - °
tion 7044 Business and Professions Code) a ADDRESS a r� , e F •-+ a? - -3
r CONSTRUCTION LENDING AGENCY .11 ' SETQBACK ' YARD` HWY�, TOTAPROPpLINEFROM 'WID H ` 14
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 _
(Sec 3097 Civ C ) ti SIDE r
4 „ PL
Lenders Name �� w , a ��_ 4', 10-100- 43 11 f
$ _ a LDMA Ref # _ _ }
fi 'PC Fee$ r Permit Fee d _U -t: r n
Lender s Acare S s
r I certify tha avepread this application and state that the Issuance Fee <LDMA P/C#
8 above infor tion is c ect-I agree to comply with all County Investigat'on,Fee
R ordinance nd S e ws relating to building construction Total Fee d L)MA Perm #
a and here ou onz representatives of this County to enter `s
upon th abo m do d property for inspection purposes
/ % SEE REVERSE FOR EXPLANATORY LANGUAGE_
$ignatur f Applicant or Agent Date ` - a F