HomeMy Public PortalAbout4857AGNES AVE_Building (2) 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
or a cert pq Sec 38 r I a
� COUNTY OF LOS ANGELES ' BUILDING AND SAFETY "
Policy NoVV11//V Company '
s r BUILDING
ElCertified copy t is hereby furnished FOR APPLICANT T FILL IN ADDRESS
LRBUILDING � �
Certified copy is filed wit e�ouyy k��gJ�g4� w A AJ&-,;!r t r
do d rtment / ADDRESS
� ♦ 5 I /■wry 1
CITY ZIP LOCALITY I 6 •
Da} Applicant _ NO OF BLDGS t NEAREST A
CE IFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT CROSS ST ' �7
COMPENSATION INSURANCE i
(This section need not be completed if the permit is for one TRACT ` ' BLOCK LOT NO S MMAAPSBOOOK F PAGE PARCEL
hundred dollars ($100)or less ) ► TEL
r r OWNER ' _ NO !� USE E MAP �-•
I certify that+in the performance of the work for which this 2 F " 4 M SPE qL fZ }
permit is issued I shall not employ any person m any manner ADDRESS 7 CONDITIONS 0-
so
so as to become subject to the Workers Compensation Laws _ OV
CITY , ZIP 1O-'/ y
Date - Applicant ARCHITECT OR TEL ; DISTRICT GP TYPE FIRE 'PROCESSED BY 0
NOTICE TO APPLICANT If after making%this Certificate of ENGINEER -- NO CONS ;ZONE
Exemption you should become subject to the Workers c) d W
Compensation provisions of the Labor Code you must forth - ADDRESS ' ,,,jjj��� N
» with comply with such provisions or this permit shall beTEL f STATISTICAL CLASSIFICATION APT CONDO Z
deemed revoked t _ , CONTRACT; 'NO r�
t� LICENSED CONTRACTORS DECLARATION LIC [�) CLASS NO DWELL UNI 5 /
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO 7
(commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP ,
and Professions Code and my licens is in full force and effect CITY CLASS BK VALIDATION
3� SQ FTw NO OF NO OF CHECK '3
License Number Lic Class! SIZE STORIES FAMILIES ONE a
+ VALUATION
DESCRIPTION OF WORK �^ NEW °a � 7
Contract/ ate 1 ^ ADD �❑ ; a d� ��T P
El am exempt under Sec s r' ALTER ❑ v 1 ITEMS 4
B&P C for This reason W REPAIR ❑ $
USE OF- _ " TOTAL 6;89 a 47
t» " Date EXISTING BLDG ! q "t DEMOL ❑ o(HECK t89.*7
Signature c APPLICAN(PRINTT ' » TEL FINAL CHECK
OWNER BUILDER DECLARATION rr / NO Z DATE ,/vl� CHANGE •60
I hereby affirm that I am exempt from the Contractor s License , 4
Law for the following reason (Section 7031 5`Business and ADDRESS A FINAL " 1"
Professions Code) I,s 1 k" - PRESENT Fmy
I ^ " 0OOO-=1 8/1b/3-;,
' DING
El as owner of the property or my employees with AD R SS �-, .--+
wages as their sole compensation will do the work and \,� tt t ` i �� `5113 1 AM 9■3
the structure is not intended or offered for sale Section LOCALITY '" "' - 1�
7044 Business and Professions Code -�( MOVING - ^TEL
CONTRACTOR ' NO i F ' +
❑ I as owner of the property am exclusively contracting f, ~`„ ,\,,1�...-,, �*�y 'AC�Tev
with licensed contractors to construct the project (Sec ADDRESS " +� `
tion 7044 Business and Professions Code ) +1� 1 '51"107 1169.:5
REQUIRED TOTAL SETBACK FROM ' EXIST p' t
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDT a
I hereby affirm that there is a construction lending agency for FRONT y - 4- �" i + 1� �. 0 1 ITEMS,
the performance of the work for which this permit is issued P L' TUTAL 1109..^.5
(Sec 3097 Civ C,) SIDE r
- P L - (HECK 1169.?1
Lender s Name
LDMA Ref # CHANGE t GI I
P C ee Perm,t Fee ) ► ■
Lender s Address y 4
o 1 certify tha I have read this application and state4that the r Issuance Fee / LDMA P/C#Y
above inf atio rect I agree to comply with all County Investigation Fee
g 9 P Y Y / p sQ— 1 Pil 1 E}!u�
R ordinan a Sta`T a;dl
lacing to building construction + Total Fee 7 LDMA Perm #
a and h y uthon re entatives of this WD
cj11¢ 1^ AM 9eL$
upo a ve ntio property for inspe
F SEE REVERSE FOR EXPLANATORY LANGUAGE _ R
� S�gnat a of Applicant or Agent
J
.tee