HomeMy Public PortalAbout4910AGNES AVE_Building (5) r �* ` v
WJQRKERS-COMPENSATION DECLARATION
Ira• I sureby cfffirm
certificate
that I have a certificate of consent to self A P P L I CATION` FOR BUILDING.PERMIT A '
insure or a certificate of Workers Compensation Insurance _ = s n y
or a certified copy thereof (Sec 3800 Lab C)
Polity No/06 / S CT� �' _ COUNTY OF LOS ANGELES BUILDING AND SAFETY
yCompany r
r BUILDING
❑ Certified copy is hereby furnished - QFOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec BUILDING ADDRESS `` (`1 N 2
tion department t s iQ _
�/ 9 CITY Q I P ZIP L � LOCALITY r r
Date ti Applicant r NO OF BLDGS }
CER IFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT NEAREST— _� S�ry
CROSS ST
COMPENSATION INSURANCE ASSESSOR s ,
(This section need not be completed if the permit is for one TRACT BLOCK M' LOT NO t MAP BOOK PAGE ` PARCEL
hundred dollars ($100)or less ) ' TELL.,.,
o ` s OWNER + 0.v S Q � NO '�� USE ZONE t MAP
"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 0. 42 "'I ISPECIAL
CONDITIONS t CL
0
so as to become subject to the Workers Compensation Laws . r V
i CIN T C ZIP r -
Cie
Date Applicant ARCHITECT OR TEL DISTRICT GROUP I TYPE rFIRE PROCESSED BY r O
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO CONST ZONE I A ►—
Exemption you should become subject to the Workers 3 W
Compensation provisions of the Labor Code you must forth ADDRESS ' P.P v �, 0-
with
with comply with such provisions or this permit shall be ` TEL 1 ' STATISTICAL CLASSIFICATION APT CONDO Z
deemed revoked y CONTRACTOR �} p O��w NO CLASS NO �" DWELL UNITSJ
LICENSED CONTRACTORS DECLARATION ADD 1 —\ �„� 3 a k NO t�-)-7 3�
I hereby affirm that I am licensed under provisions of Chapter 9 , 1 Q SEWER MAP
(commencing with Section 7000)of Division 3 of the Business CL /' ^-3 -V a
CITY ro lLty 0. 61 N CLASS Cr VALIDATION
r and Professions Code and my license is in full force and effect BK PG
i SQ FT NO OF NO OF CHECK "
License Number-4;;' (3� ` Lic Class r`� SIZE STORIES FAMILIES `� ONE VALUATION
Contractor \�00�� 1e S 2/ q DESCRIPTION OF WORK NEW ❑ ; / `�w Z Q °
r Q 0 0 ' ADD ❑ C� ►
❑I am exempt under Sec -
ALTER ❑ �
n
B&P C for this reason O µ `� �� REPAIR ❑ $
Date USE OF_ 1 n µ ❑ °
EXISTING BLDG Q S dl Q r.., r` DEMOL
Signature APPLICANT �{-�-� TEL 'i-
(PRINT) FINAL
A ` O V lNO ^� �'7` f(r +
OWNER BUILDER DECLARATION ir DATE ) r
I hereby affirm that I am exempt from the Contractor s License II t S
S
Law for the following reason (Section 7031 5 Business and ADDRESl \� W 3 FINAL ] t "
Professions Code) PRESENT
BUILD
IG
ElI"as owner of the property or my employees with ADDRENSS __
wages as their sole compensation will do the work and _
the structure is not intended or offered for sale(Section LOCALITY ab ^ , '� ` r
7044 Business and Professions Code ) MOVING r TEL
❑ I as owner of the property am exclusively contracting CONTRACTOR NO A,--
with
-
with licensed contractors to construct the project i(Sec ADDRESS
tion 7044 Business and Professions Code ) + -4r- f ` 1 r
REQUIRED TOTAL SETBACK FROM EXIST ti
CONSTRUCTION LENDING AGENCY i SET BACK YARD HWY PROP LINE WIDTH r
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued PL
(Sec 3047 Civ C) SIDE
Le'nder s Name P Li�--
LDMA Ref # ,
PC Fee$ Permit Fee e - r ? •+� _
Lender s Address �J�f
o I certify that I have read this application and slate that the Issuance Fee LDMA P/C#
above information is correct I agree to comply with all County Investigation Fee Q S
Rordinances and State laws relating to building construction Total Fee LDMA Perm #
a and hereby authorize representatives of this County to enter
u e ve mentioned property for mspectio purposes � � s "
' t s
s ? SEE REVERSE FOR EXPLANATORY LANGUAGE__
Signature of Applicant or Agent Date t a
1