HomeMy Public PortalAbout4901AGNES AVE_Building (5) EENSATION DECLARATION
I •` h4 kes' Compensation Insurane, APPLICATION FOR B.UI DING PERMIT'
nsure, o to of
or o certified copy thereof (Sec. 3800, Cab. C.) -
COUNTY OF LOS ANGELES BUIL ING AND SAFETY
Policy No.2�f3j Company _
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING GH�
ADDRESS
Certified copy is filed with the county'building inspec- BUILDING �( ,/. NQ dL� C �A
tion department. ADDRESS ,p iF r ,
DateZ Applicant CITY r L� G/ ZIP LOCALITY
CERTIFI ATE OF EXEMPTION FROM WO ERS' SIZE OF LOT NOW ON LOTS I CROSSNEAREST. •, [�a�iE,2 A?ksA IAD
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP'BOOK PAGE PARCEL
TEL.OWNER C � USE Z NE MAP
Q_ Ilf.— //V\ -- NO. —513
('certify that in the performance of the work for which this NO. y.
permit is issued, I shall not employ any person in any manner I SPECIAL IL
so as to become subject to the Workers'Compensation Laws. ADDRESSp� H� CONDITIONS 10
CITY I Le CA. .ZIP.
Date Applicant ARCHITECT OR TEL. O.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEDISTRICT GROUP_, CONST ZONE PROC SED BY
ER NO.
I
Exemption, you should become, subject to the Workers' p /
Compensation provisions of the Labor Code, you,`must forth- ADDRESS ^ - i0
with comply with,such provisions or this permit shall be
/4tj+f�,� TEL. STATISTICAL CLASSIFICATION APT. C NDO.
CONTRACTOR D NO-4'7660-2751 deemed revoked. 6/D—
LICENSED CONTRACTORS DECLARATION -LIC. CLASS NO. Z DWELL. UNITS
I hereby affirm that.I am licensed under provisions of Chapter 9 ADDRESS,2 F!(/� NO. a'S SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and -LIC. y�
Professions Code, and my license is:in full force and effect. CITY 1.- G C CLASS a BK VALIDATION `
SQ. FT_. INC.OF NO. OF CHECK
License Number Lic.Class / SIZE - STORIES FAMILIES ONE
VALUATION do
Contractor Date L DESCRIPTION OF WORK f NEW ❑ $r 7�
iwRoa%5 c-{v Rc�r"I ADD _ , 6-5 Q 7'A
❑ I am exempt un r Sec. ALTER ❑ ` # 0 0 0 0 23
B,&P.C. for this reason A(• JC. REPAIR. ❑ $
Date: USE OF A� 1t1 �I`o 33597
EXISTING BLDG. �L tGG•+II,�L� DEMOL ❑ - -
Signature APPLICANT TEL. FINAL /,�Tf
OWNER-BUILDER DECLARATION '
(PRINT) /1L9°►CbLRF7LI NO. 6D-.ZcTr C vr- x
I hereby affirm that I am exempt from the Contractor's License Id.�T` 0 a 3 3 5,9 7 5
Law for the following reason (Section 7031.5, Business and ADDRESS 'Z Ji W- Gt*V VE, I GaY/I� FI
Professions Code): PRESENT
0,21 2-87
❑ BUILDING -
I, 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 ,•
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project'(Sec- ADDRESS ~
tion 7044, Business and Professions Code). (�7 O,'6 A
REQUIRED TOTAL SETBACK.FROM T.
CONSTRUCTION LENDING AGENCY SET BACK YARD 'HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT # 0 0'0 0 e.1
the performance of the work for which this permit is issued P.L.
(Sec. 3097, civ. C.). SIDE 1 4'0 5.75
P.L.
Lender's Name jr 'o 0
o z ,[�' ` LDMA Ref. # 4.0 5.,7 5
- P.C. Fee$ �J Permit Fee 1�•
Lender's Address _ 0-3.210-87
.I certify that I have-read this application and state that the Issuance Fee CJ LDMA.P/G-#•`,
above information is correct. I agree to comply with all County Investigation Fee
m ordinances and State laws relating to building construction, Total Fee• LDMA Perm. #
d and hereby authorize representatives of this County to enter `
upon the abq6yrnentio d roperty for inspection purposes.
a SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Ap li nt or Agent 4D e - - - -" - -