HomeMy Public PortalAbout4851AGNES AVE_Building 14
WORKERS COMPENSATION DECLARATION �� L3
hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING P E RM I T
insure or a certificate of Workers Compensation Insurance "
or a certified co t* f (Sec 3800 C ) COUNTY OF LOS ANGELES BUILDING A, SAFETY 4
r< PolicCompany U�. BUILDING
..,
f ❑ 'Certified copy is hereby furnished F)-APPLICANT TO LL IN ADDRESS ✓ti`
Certified copy is filed with the county budding mspec BUILDING
�tison ep ment ADDRESS
>7aTe ` 'APPlicant CITY QIP LOCALITY L
N OF BLD S NEAREST
+ ER FI TE OF EXEMPTION FROM WORKERS SIZE OF LOT O O X 3/ NOW ON LOT CROSS ST Al
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT 4ML2EK I LOT hM Alf. /' MAp BOOK PAGE PARCEL
hundred dollars ($100)or less ) « " TEL / USE ZONE t MAP
r OWNER NO NO T 11Dp
I certify that in the performance of the work for which this QUI -SPECIAL
permit is issued I shall not employ any person in any manner ADDRESS CONDITIONS
AS
so as to become subject to the Workers Compensation Laws + O
• , 9 CITY ZIP U U
Date Applicant ARCHITECT OR A TELE FIRE
NOTICE TO APPLICANT If after making this Certificate of ENGINEER + NO DISTRICT GROUP ONST + ZONE PROCESSED BY
Exemption you should become subject to the Workers Q - W
'Compensation prov&ons of the Labor Code you must forth ADDRESS 6Q 3 N
with comply with such provisions or this permit shall be r EL STATISTICAL CLASSIFICATION / APT CONDO Z
w deemed revoked CONTRA NO
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNIT -.I�r
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP L a Z- ''
1 "
(commencing with Section 7000)of Division 3 of the Business LIC -
and Professions Code and my lic e i n full force and effect CITY CLASS BK PG ;+ 1VALIDATION`.g „ ,;tC-
► 007 �_ SIQ STORINO IEES AMILLIIES ONE K E
License Num�b]er�� LicxClass p VALUAT ON/f 4 �r
l_ (/�/ + f� DE' O WORT' NEW $ VDD-� _t _4
Contractor a e
ADD ❑ s ►
❑I am exempt under Sec ' ' -
ALTER ❑
B 8P C for this reason $
t Date USE - REPAIR ❑ �tis{1" j At"aFf1Lr --r
EXISTING BLDG - DEMOL ❑
r Signature APPLICANT L i FINAL -
OWNER BUILDER DECLARATION (PRINT O u� DATE
I hereby affirm that I am exempt from the Contractors License
Law for the following reason (Section 7031 5 Business and ADDRESS FINAL ( 1
Professions Code) p PRESENT - - By ACC
BUILDING + 1'C T■T '
❑ I as owner of the property or my employees with ADDRESS v `
wages as their sole compensation will do the work and -4 '""' !' : + `
9 P � � i 169.
the structure is not intended or offered for sale(Section LOCALITY , e 3
7044 Business and Professions Coble) MOVING - TEL < " C -Si ITEMS
LI TTCMG S t
' ❑ I as owner of the property am exclusivdly contracting CONTRACTOR NO ti ` �" t r ne
. �-`- fOTAL - 1164
with licensed contractors to construct the,pro4ect (Sec ADDRESS � � � \ ..1,` '�`* � .`
tion 7044 Business and Professions Code ) c . ` ''\` a /'�L(�t�llt� p ne
REQUIRED TOTAL SETBACK FROM EXIST + - ` " `�'' 41 `CHECK 1'167■r �
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH t O t %)
Ihereby the performfirm that ance ce ofthere is a the workcWwhiicion h this npermiitt is issued (ued for FRONT �to-�1 �;tom ` E ■Q[I
(Sec 3097 Civ C ) � SIDE
i 1 PL 7 �c
Lenders Name ,� M-0001 3/16/29
• r LDMA Ref #
Lender s Address + P C Fee S • Permit Fee J /t rt y V ci11d 1 d AM Q:,+.
1 certify t aerelating
pkation and state that the Issuance Fee U r� LDMA P/C# -
8 above rree to comply with all County Investigation Fee Q J
R ordin aing to building constru"tion Total Fee / LDMA Perman eby otrves of this County enteru th boerty for mspectio rpose
r
SEEaREVERSE FOR EXPLANATORY LANGUAGE
Si re of Applicant or Agent ate r