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Home My Public Portal About4908AGNES AVE_Building (4) WORKERS COMPENSATION DECLARATION *> al herebyaffirm that I havela certificate ofrconsent to self , insure w a certificateofWorkers Compensation Insurance ' APPLICATION FOR Diu,I L D I N G 'P E RM I T� �` for a certified copy therieof(Sec t 3800 Lab C ) ` '' - "3 - a , t Policy No�, mpany t) Co - w`� '' ` a + M COUNTY OF LOS ANGELES _ BUILDING AND SAFETY - a tt Certified co furnished .ti ' r 'FOR y t~ ❑ copy is9hereb y fhd FOR APPLICANT TO FILL IN ADDRESS i ❑' Certified copy is filed with the county building inspec ` ' BUILDING tion department a ° «* ADDRESS i A Date .1, Applicant r i 1 - CIZY - ZIP LOCALITY I ` CERTIFICATE OF EXEMPTION FROM WORKERS _ " -" © , NO OF BL S - NEAREST '' t3 sq rI COMPENSATION INSURANCE" sx1� r SIZE OF LOT NOW ON LOT -+ CROSStST (This sectionsneed not be completed if the permittis for one - q ` -,'" �- • ,- . `—,�x ASSESSOR R -� i a t t hundred dollars ($100)or less ) ,,y t r TRACT BLCK K LOT NO ", MAP BOOK k"'i PAGE PARCEL r h. t d la.r , OWNE t 111VTEL USE Z NE MAP I+certify that in,rthe performance of the work for which this NO NO +t + r permit is issued I shall not'employ any pe'r'son in any manner _ +SPECIAL so as to become subject to the Workers+Com ensation L`w ADDRESS - �'"' �" CONDITIONS i +i + t V a ort is al�'tr ad+a s F tot' t h - �i t i __ ` h R, t �tAt rug- , _ C Y .ry.- ZIP_.. 7G/D-.'-f - - t i s r .. O Date Applica t , ARCHITECT O ,'s 'T TEL + w rt i NOTICE TO APPLICANT If after maker this C -tate of , DISTRICT_, GROUP TYPE FIRE PROC ED BY t G Exemption you`should become subjects to the°Work-s ENGINEER N n CONST / ZO Compensationtprovisions ofsth- Labor Code you musttfor _ ADDRESS - ' _s.c , _ _ K, O� _R:3 _ _.sV__ �-1 _ �_ _1 y with comply witht`isuchr provisions or this perm-tt shall be ,w -i- -. __ _Y - - TETE ^� STATISTICAL CLASSIF CATION ' 4 APf C DO ' Z o deemed revoked-*e t t 1 ,, h, , Ir i ' ti r, , CONTRACTOR • NO , _ LICENSED CONTRACTORS DECLARATION UC_ _ _ - CLASS NO .7, L UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO i 1 commencin with Section 7000 of Division'3 of the Business and . SEWER MAP t (, w ag k ) • _ - .. .._ i+ LIC r _ - cr y , Professions Code and my license ist-nt�full force and effect CITY CLASS , VALIDATION ` J, 0 VAt+ .g ; L- + SQ FT NO OF NO OF _ CHECK BK , t s License,Number ' Lic Class'` r SIZE' STORIES ' - FAMILIES ` -. ONE , gar,, VALUATION DESCRI NOF WORK ' NEW "'❑ /��f )QD ' 'Contractor r ` � Date .-. ADD $ r —r .... ❑ I am exempt under Sec - - -- - tic+ t i Ur<t t rtt� 9 t a ALTER _O t t M o + t B&P C for this reason USE OF A - REPAIR- ❑ °�$ - i t - 122 2 a 6 A �# t EXISTING BLDG DEMOL ❑ 0 0 oi ' Signature - APPLICANT " TEL FINAL LATM 1 OWNER BUILDER DECRATIO N G NO i -I herebyaffirm that I am exempt from the Contractor s License PRI - _ _ DATE - - I1�° 1 8 1 3 Law fothe following reason(Section 7031 5 Business and ADDRESS �' ! FINAL • 8 1,35 - ., 0 Prof sions Code) - � . "'a"" '� "' "' ' " -- ' PRE 7 By "' IS 1-9-815 t t"' I as owner of the property ow BUILDING my employees with., + ADDRESS wages as then sole compensation will do the work and s the structure is not intended or offered for sale(Section' LOCALITY : - r t► , 1 ' ` 7044 Business and Professions Code) a L" '-- MOVING' T' -' `" TEL t ❑_ I as owner of the property am exclusively contracting CONTRACTOR NO with licensed contractors to construct the"project (Sec' - -- « -^" -- -s;' t qw r tion 7044 Business and Professions Code) ADDRESS 4 , L. - ,. REQUIRED _ TOTAL SETBACK a CONSTRUCTION LENDING AGENCY' SET BACK YARD HWY PROP LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT t the performance�of the work for which this permit is issuedlK - ---P L y - 4Y _ r , • a a _ _ _ (Sec 3097 Civ C ) SIDE 4 ,. r •.... ,. xt_... .. i P L—. '' - t r t�l+l , .x`J Lender s Name _ _ _ _ t F Fee Permit Fee �LDMA'Ref _ pr P C- $- ', - 3 ` t Lender-s Address + `' i N L,certify that 1-have-read this application and state that the ' ---� Issuance Fee -� U + LDMAP/C# a g above information is correct I agree to comply with all County Investigation Fee ~ 'W� ordinances and State jaws relating to building construction vr._ u _`3 ,{ I- ✓t #-- •-*w• - - a and hereby authorize representatives of this County to enter Total Fee LDMA-perm ", j_ upon the abo m ntion p or inspection purposes M ! r SEE REVERSE FOR EXPLANATORY LANGUAGE ! + I T + Signature of -cant or Ag4q! f - - -Date - - ^ - -` - - - - +- - A - -4 __ _ Or - .e "