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HomeMy Public PortalAbout4913AGNES AVE_Building (4) �ORKERS' COMPENSATION DECLARATION I hereby (affirm that I have a certificate of consent to self APPLICATION p p L I�AT I N F R -BUIL®I IV PER I T insure, o11a certificate of Workers' Compensation Insurance, O O G M t or a cerANfied copy thereof (Sec. 3800, Lab. C:) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicysNo. Company ❑x_ Certified copy is.hereby furnished: FOR APPLICANT TO FILL IN. BUILDING ADDRESS l ❑ Certified copy is filed with the county building irispec- BUILDING �s tion department. ADDRESS 7JJ. 14 r, -jtail ' mm Date Applicant CITY'S _ ZIP _ 6Q LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST. COMPENSATION'INSURANCE SIZE OF LOT f, /9 D,0`I-• NOW ON LOT CROSS ST. et (This section need not=be completed if the permit is for one ASSESSOR Vr hundred dollars ($100)or less.) TRACT BLOCK / LOT NO. MAP BOOK PAGE PARCEL OWNER ° TEL.. USE ZONE MAP I certify that.in the performance of the work for-which this $ NO' `� a""' NO. } p'ermit_is issued, I shall not employ any person in'any manner r �� SPECIAL d so as to become subject tc the Workers ?Compensation Laws. ADDRESS v - M CONDITIONS 00 PP l�?� =vr' CITY ri ,( ZIP pC Datel&af A lic ARCHITECT OR TEL. O NOTI TO APPLICANT: If, fter making: this Certificate of DISTRICT GROUP TYPE FIRE PRO ESSED BY �. ENGINEER NO. CONST. ZONE Exemption, you should become subject to the Workers' /�(� Compensation•provisions of the Labor Code, you-must forth- ' ADDRESS (fid R_ J l- with comply, 'with such provisions or this permit shall• be rA deemed revoked. TEL. STATISTICAL CLASSIFICATION I APT. JJNDO.- Z CONTRACTOR 114J' NO. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. , DWELL UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK - ' FG VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic.Class SIZE 70 ISTORIES FAMILIES ONE s VALUATION Contractor Date DESCRIPTION OF WORK NEW $ 77 - ADD ❑ ❑ I am exempt under Sec. ❑ - ALTER B.&P.C. for this reason REPAIR .❑ 3. ' Dare: USE OF EXISTING BLDG. - I� DEMOL ❑ Signature APPLICANT LI 4 - NO I ��- FINAL _ _ OWNER-BUILDER DECLARATION PRINT > ' DATEi�.. �424,7..A I hereby affirm that I am exempt from the Contractor's License , , Law for the following reason (Section 7031.5, Business and ADDRESS _,si � FINAL '1 Professions Code)'' - PRESENT BUILDING - I, as owner of the properly, or my employees with ADDRESS v � c o 3 3,0 Q wages as Their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY f `o 0 0 3�•0 0 Pi 7044, Business-and Professions Code). MOVING TEL. ' - ❑ I, as owner of theproperty, am exclusive) contracting CONTRACTOR NO. v g _ '03, 18-86 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY SET BACKD YARD HWY TOTALSETBACKAINEFROM EXIST.WIDTH I hereby affirm that there is a construction lending agency for FRONT 1 ' the performance of the work for which this permit is issued P.L. -- (Sec. 3097, Civ. C.). SIDE �--- P.L. Lender's Name LDMA Ref. # P.C. Fee$ Permit F _ .. . - - Lender's Address _ I certify that I have read this application and state that the Y PP Issuance Fee�Q LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to•building construction, Total i LDMA Perm. - d and hereby authorize representatives of this County to enter upon t e above-mentioned ope�forspection purposes. a �'� SEE REVERSE FOR EXPLANATORY LANGUAGE Ignatvreof A plicantorAgenDate- - - - - - •- - - - - - -©