HomeMy Public PortalAbout5112AGNES AVE_Building WORI'ERS COh_pENSATCr4 DECL,*ATION - x
APPLICATION FO BUILDING PERMIT
I hereby affirm that�I have a certificate of consent to self
insure or a certificate of Workers Compenstion Insurance or
a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELS e BUILDING AND SAFETY
�P❑ohcy No Company DULDIN
�7
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRES257// �G
❑ Certified copy is filed with the county building inspec BUILDING ��}} / ol
tion department ADDRESS ��aC C� ��% J� LOCALITY .d
NEAREST ;
Date Applicant CITY ZIP CROSS ST
I CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS r ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT �� NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one UStWON MAP
hundred dollars ($100)or less ) TRACT \ BLOCK LOT NO Ir`' NO >_
7 Y SPECIAL d
OWNER/y.5_ S / CONDITIONS O
I certify that in the performance of the work for which this - _
permit is issued I shall not employ any person to any mannerISTRICT GROUP TYPE FIRE PRO ESSEX BY
s V
ADDRESS (✓/G� I"H/ CONST ZC�CIF�
so as to become subject to the Workers Compensation Laws 'f`,�
CITY �! � e O
Date Applicant ZIP STATISTICAL CLASSL4CATION APT CONDO U
NOTICE TO APPLICANT If after making This Certificate of ARCHITE OR- /� T TEL ,/ LU
Exemption" you should become subject to The Workers ENGINEER J d (� /� /� NO�9S',Z _ CLASS NO DWELL UNITST / y
Compensation provisions of the Labor Code you must forth ADDRESS �! SEWER MAP
with comply with such provisions ori this permit shall be ��,// '
deemed revoked CONTRACTOR / (.!/�l/�}�' d NO /�'�' BK PG 7�TEI VALIDATION
LICENSED CONTRACTORS DECLARATION LIC/JI�
hereby of that I am licensed under provisions of Chapter 9 ADDRESS / /�' NQfOs 2 ^VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code and my license is in full force and effect CITY Z. _ J CLASS $
SQ FT NO OF NO OF CHECK
License Number Lic Class SIZE d�' STORIES FAMILIES / ONE
fContractor Date D SCRIPTION OF WORK $!tea
❑ 1 am exempt from the licensing requirements as I am a t�
licensed architect or a registered professional engineer ALTER ❑ FINAL �J_�� Q TJ�
acting in my professional capacity (Section 7051 REPAIR ❑ DATE Q 3 1 9 2 a
Business and Professions Code) USE OF FINAL
EXISTING BLDG DEMOL ❑
Lic or Reg No Date APPLICANT J , By # o+o o e 2 3
OWNER BUILDER DECLARATION PRINT)
I hereby affirm that I am exempt from the Contractor s License t7r-- ` 2 ° ° 9 1 2 0
Law for the following reason (Section 7031 5 Business and ADDRESS
Professions Code) PRESENT _ � / �
° eie91 2026
BUILDING
I as owner of the property or my employees with ADDRESS - �t�`7 �i+' 0309-82
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code) MOVING TEL
F_] I as owner of the property am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec ADDRESS z 3 1 9 3 A
tion 7044 Business and Professions Code)
REQUIRED TOTAL SETBACK FROM EXIST
i CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH # ° e e e e 1
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P L 2 e 7 3 7 5 0
(Sec 3097 Civ C ) SIDE
PL ao73750c
Lende-s Name _
Lender s Address P C Fee$ 9�� C10 Permit Fee 'F��. 0 309-82
' t
1 certify that I have read this application and state that the -20 Issuance Fee . �' Q
J
above information is correct I agree`to comply with all County Investigation Fe -
ordinances and State laws relating to ibuilding construction Total Fee 73 -7, S 0
and her by authonz re sentat ives of this County to enter
t
upo th ad property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sies
gnature of pphcant or Agent Date