HomeMy Public PortalAbout4926AGNES AVE_Building (3) WORKERS'COMPENSATION DECLARATION
.a. ,affirm that I haveAPPLICATION F®R.' BUILDING PERMIT
r a certifidbte of Workers'
certificate of consent to self kers'Compensation Insurance,
ce—'lied copyahereof (Sec. 3800, Lab. C.) COUNTY PF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified co is hereby furnished. UILDING
❑ copy y FOR APPLICANT TO FILL IN A DRESS !L'
❑ Certified copy is filed.with the county building inspec- BUILDING
tion department. ADDRESS LOCALIT
/p `7'' 7 NEAREST
Date Applicant CITY (�� (,'� ` ZIP cf! CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. bF BLDGS. -ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW.ONAOT. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one U ONE MAP /
hundred dollars ($100)or less.) TRACT BLOCK LOT'NO. '1Q NO. YCi
TEL. ` 7 / SPECIAL �-
I certify that in the performance of the work for which this OWNER A OCYVU ,NO��6_' ! CONDITIONS 126
permit is issued, I shall not employ any person in any manner �' DISTRICT GROUP TYPE FIRE PROCESSED BY
so as to become subject to the Workers'Compensation Laws. ADDRESS 2 CONST.L/ ZONE
- S,o� 3 - cc
Date Applicant CITY ZIP STATISTICAL CLASSI IC TION APT. ICONDY
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR Q� n.•v� TELA
Exemption, you should become subject to the Workers' ENGINEER /7 /�J NO. CLASS NO. DWELL. UNITS
Compensation provisions of the Labor Code, you must forth- tit
ADDRESS SEWER MAP
with comply with such provisions or this permit shall be �m-
deemed revoked. g� No VALIDATION m
CONTRACTOR 5 ��vC� BK. PG,
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATIO _0
(commencing with Section 7000)of Division 3 of the Business and LIC. — �
Professions Code, and my license is in full force and effect. CITY CLASS $ ,
SQ. FT., NO. OFNO. OF CHECK
License Number Lic.Class SIZE Z6700 ISTORIE,
FAMILIES ONE
Contractor Date DESCRIPTION OF WORK
NEW ® $
❑ I am exempt under Sec. aT& — tf L ALTER FINAL ,
B.&P.C. for this reason DATE �� �.' 0 - 78, 00
REPAIR
Date: USE OF E] FINA x
EXISTING BLDG. DEMOL
Signature APPLICANT TEL. BY Q
OWNER-BUILDER DECLARATION PRINT NO.
I hereby affirm that I am exempt from the Contractor's License �x-
Low for the following reason (Section 7031.5, Business and ADDRESS --
Professions Code): PRESENT s�
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and P
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).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ,
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
m
P.L.
Lender's Name
Lender's Address
P.C. Fee$ Permit Fee 6• (J
W I certifythat I have read this application and state that the IJ—0
PP Issuance Fee
above information is correct. I agree to comply with,all County Investigation Feep-
$ ordinances and State laws relating to building construction, Total Fee a
v and hereby authorize representatives of this County to enter
upon the abode ntioned grope ty for ins ection purposes. t�
�� SEE REVERSE FOR EXPLANATORY LANGUAGE
D e
Signature of Applicant or Agent ! '' ' ®s