HomeMy Public PortalAbout5002AGNES AVE_Building (4) WORKERS'COMPENSATION'DECLARATION 860570• SB ` • ' '
insure, afcertif cairm ne of Worke s' Compensation Insurancificate d consent to e` APPLICATION FOR ..B VI L D I N G PERMIT .
6r-6 certified copy thereof (Sec. 3800,"Lab C.)• '-`
. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑Policy No0007 14 f; Company, R e� 2r� 'T•TS.
Certified
-
copy is hereby furnished. :: FOR APPLICANT TO FILL IN �j
Certified co is filed with the count buildiri 'in's ec- -
BUILDING
ADDRESS
® Pe Y 9 , p BUILDING 5002. Agnes Ave.
Tion department. ADDRESS �
Date 1'0/ 10/86 ,Applicant Virgin"Roof, Co CITY Temple City ZIPLOCALITY ,
CERTIFICATE OF"EXEMPTION FROM WORKERS" NO. OF BLDGS.,w NEAREST U _.. .
COMPENSATION'INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This,section need not be completed ifthe permit is for-one ASSESSOR
-hu Ind red,doIlars ($100)or-less.) TRACT BLOCK LOT NO. MAP BOOK PAGE. PARCEL
TEL. USE NE MAP
,..L
OWNER i1y Nlelkonian No. — 2
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 5002-Agnes Ave., ._ SPECIAL; -• IOL
so as to become subject To the Workers'-Compensation'Laws. ADDRESS CONDITIONS O
CITY Temple City zip U
Date Applicant ARCHITECT OR TEL.
NOTICE TO•APPLICANT'•If,"after mbking this Certificate of DISTRICT.. GROUP ,TYPE FIRE. P CESSED BY
ENGINEER No. CONST. ZON 0
Exemption, you.•should 'become subject to the 'Workers' a rd
Compensation provisions-of The Labor Code,'you must forth- ADDRESS �v
with -comply with;such provisions or.this.permit shall be" TEi. CA
deemed`revoked., CONTRACTOR Virgin Roof CO NO 287-0507 STATISTICAL CLASSIFICATION' APT. CONDO.. g
LICENSED CONTRACTORS DECLARATION. --- - -- "LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS P 0 Box J NO. 160650
(commencing with Section 7000)of Division 3.of the Business and LIG. SEWER MAP
Professions Code, and my_license is in full force and effect. CITY Sari GAbriel CLASS C39 BK. . PG. VALIDATION
License Number 160650' Lic,Class C39 • - SIZEQ.FT. 2600 STORINO. IEES 1 AMWES CONEK
❑ VALUATION .. .
Contractor Virgih ROOf; CO - Dote• 10/']0/86 DESCRIPTION-OF WORK Tear off existing NEW
❑ S 5000.00
ADO
❑ I'am exempt under Sec. shakes and• reroof. house & .- ar jqq ❑
eLTER ,
B.&P.C. for this reason P71th Class A fiberglassshing FAIR ❑ $ _ t
Date: USE
EOEXISTING BLS 6 s q.uar e s dG. we l l in DEMOL El
APPLICANT TEL.
Signature "" FINAL
OWNER-BUILDER DECLARATION PRINT) Virgin Roof. CO NO`287-0507 DATA J
I hereby-affirm that I am exempt,from.the•Contractor's License P 0 Box J, San Gabriel 9 1 778 v
Law for the following reason.(Section 7031.5, Business and ADDRESS FINA %
Professions Code'):
PRESENT BY
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 [AD
TRACTOR NO. F ,lS7A�
with licensed'contractors to construct the)project (Sec ESS p` l !) ;25629A '
tion 7044, Business and Professions Code). VV V (f e y�
YARD HWY TOTAL SETBACK FROM I .� 7 D#GI®VCONSTRUCTION LENDING AGENCY BACK PROP. uNE WIDTHI hereby affirm that There is a construction lending agency for ONTthe performance of the work for which this permit-is issued .(Sec. 3097, Civ. C.). ELender's NameLDMA Ref, #
ee$. - Permit'Fee - - - - ,67.50Lender's Address / -t I certify that I:have.read this application and state.That the Issuance Fee 10:50- LDMA P/C#above information is correct. I agree to comply with all County tigation Fee
78.
00
m ordinance and State Iaws relating.to building construction, Total Fee LDMA'Perm. #"and here y authorize representatives f this County To enter
,. upon Th ove-mentioned pro rty f r ction pur oses.
a D SEE REVERSE FOR EXPLANATORY LANGUAGE
Ig; 4aur f Applicant or Agent - Date° Qv i