HomeMy Public PortalAbout4859AGNES AVE_Building WORKERS' COMPENSATION DECLARATION
' I hereby affirm that I have a certificate of consent to self PLACATION FOR BUILDING PERMIT
insure,,or a certificate of Workers' Compensation insurance,
or p certified copy ther f (Sec. 3800 ab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic P� Company
BUILDING
❑ Certified copy is hereby.furnished. FOR PPLICANT T FILL IN ADDRESS
Certified copy,is filed with the county building inspec- BUILDING
?mss_ tion epa tment. ADDRESS
6 • Date Applicant CITY ZIP all � LOCALITY
NO. OF BLDGS. NEAREST
C R ICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT �� NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT' BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) NO. USE ZONE MAP
OWNE
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any manner ADDRESS � / SPECIAL
CONDITIONS G
so as to become subject to the Workers'Compensation Laws. O
CITY maw,, ZIP U
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT AT
P CON ZONE TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers' wCompensation provisions of.the Labor Code, you must forth- ADDRESS (� 0_
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACT NO. Z
�—
LICENSED CONTRACTORS DECLARATION LIC.��``� CLASS NO. DWELL. UNIT
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS a. '" No.`+zg /
LIC. EWER MAP
(commencing with Section 7000)of Division 3.of the.Business � a ,-;
and Professions Code,and my I' n ' in full force and effect. CITY T CLASS BK PG '-' VALIDATION
SQ. Fyye� NO. OF NO. OF CHECK 4 A
License Number 'Lic. Cla SIZE y STORIES FAMILIES ONE., f�t•�.•� oT
Contractor Da1e It, DESCRIPTION OF WORK (films/ NEW >< $ '7307 ITEMS
984.95
❑I am exempt under Sec. • G/�, y ADD ❑ , 1 ITi'IS
ALTER ❑
TCITAL 984 - 95
B.BP.C. for this reason REPAIR ❑ $ C
+. Date: USEEXIGING BLDG. S DEMOL ❑ CHECK 984.`!_
Signature APPLICANT (` L. ` ;RANGE n1flLf
g OWNER-BUILDER DECLARATION (PRINT N7� NO DATEFINAL
I hereby affirm that I am exempt from,the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS / L d" FINAL (10((0_11001 '33/16/2-9
Professions Code): PRESENT By t AM i
BUILDING / ;108 1 AM �1
y';
El 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY pop 7.044, Business and Professions'Code.) MOVING TEL. •❑ <j•ff I, as owner of the property, am exclusively contracting
CONTRACTOR NO. WC.0 I a c T
with licensed contractors to construct the project (Sec- •�++(J! 1itiC7'oJ
tion 7044, Business and Professions Code.) ADDRESS EM
REQUIRED TOTAL SETBACK FROM EXIST. ' 1 ITEMS
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT TOTI AL 1169. `
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE i•HtC 1169. �
P.L.
Lender's Name. CHANGE .00
m ( Q ' LDMA Ref. #
P.C. Fee$ J Permit Fee OO
Lender's A dress
0 .114
1 certif at I h read this application and state that the Issuance Fee V.J 6 LDMA P/C#
8 abov i or ton i correct. 1 agree to comply with all County Investigation Fee / / / C iL, f ( {� o 11
o ordi s and S to laws relating to building constru ton, Total Fee / (� _. LDMA,Perm. #
a an eby aut rize epresentatives of this County ent
t abov -men oned property for inspectio
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig oture of Applicant or Agent Do .