HomeMy Public PortalAbout5117AGNES AVE_Building (5) rRKERS COMPENSATION DECLARATION t
reuy�affirm that I havecertificate of consent to self APPLICATION FOR ,BUILDING PERMIT "
insure or a certificate o't Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lab_C ) 1
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No - Company '
F] Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING
ADDRESS 7-AWNU
Certified copy is filed with the county building inspec BUILDING K
tiorT department P , ADDRESS
i if '% t
J6ALS Al /1 Ja-
Date Applicant x CITY C rr ZIP LOCALITY If-ZA'11
CERTIFICATE OF EXEMPTION FROM WORKERS + > NO OF BLDGS , NEAREST
9 COMPENSATION INSURANCE SIZE OF LOT 3 NOW ON LOT 4 CROSS ST
(This section need notibe completed if the permit is for one TRACT BLOCK LOT NO ASSESSOR MAP BOOK PAGE PARCEL
hundred dollars($100)or less )
OWNERN L -� USE ONE MAP n
I certify that in the performance of the work for which this /y/� NO
permit is issued I shall not employ any person in any manner ADDRESS /O(P I SPECIAL
so as to become subject to the Wor hon+L s U
Dat Applica t CITY �r ZIP
NOTICE�TO APPLICANT If a r makt this Certificate ARCHITECT OR TEL DISTRICT G UP TYPE FIRE PROCESSED BY
ENGINEER NO
Exemption you should become subject to the Workers /� CONSIT ZONE U
Compensation provisions of the Labor Code you must forth ADDRESS ✓ t/ w✓ �
+ with comply with such provisions or this permit shall be < `
deemed revoked C O STATISTICAL CLASSIFI ATION APT C NDO (n
CONTRACTOR J Z
LICENSED CONTRACTORS DECLARATION // LIC CLASS NO DWELL UNITS
-
I '�KC—
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 r CLASS BK �C—PG VALIDATION
�j SQ FT NO OF NO OF CHECK
License Number �a Lic Clams, /S SIZE c';7STORIES r FAMILIES ONE
/� r^ �/ VAL�Uf AT ON
Contractor) ft� �h e ` DESCRIPTION OF WORK ADD
D ® $ �/
O`, ti
I am exempt under Sec a
ALTER
B&P C for this reason REPAIR $
USE OF '
Da EXISTING BLDG DEMOL
Signature APPLICANT TEL FINAL
R DEC ATI N PRINT N DATE ✓
I hereby a t 1 am exempt from t ontractor s License
T Law f ollowing reason (Section 1 5 Business and ADDRESS FI L
Professions Code)" - PRESENT
BUILDING
I as owner of the property or y employees with ADDRESS
wages as their sole compensation ill do the work and y
the structure is not intended or offered for sale(Section LOCALITY t y s
7044 Business and Professions Code) r MOVING TEL - _+ i�`9 0 2 9 R
P
* CONTRACTOR NO # o 0 0 • O11 ,
I as owner of the property am exclusively contracting �-
' with licensed contractors to construct the project (Sec ADDRESSr e j J E
hon+7044 Business and Professions Code) v } t ° 2 6 5 5 0
REQUIRED TOTAL SETBACKt ,s
" CONSTRUCTION LENDING AGENCY' SET BACK YARD HWY PROP LINE a WIDTH rt< - z,. " e o
1 hereby affirm that there is a construction lending agency for FRONT 2 6 5
the performance of the work for which this permit is issued P L 0223-88
(Sec 3097 Civ C ) SIDE t '
P L
Lender s Name
SSS LDMA Re
Lender s Address
f f+ f y ti d
m P C Fee$ Permit Fee t T
1-certify that I have read this application and state that the Issuance Fee_ V LDMA P/C q
above information is correct I agree to comply with all County Investigation Fee /�
0 ordinances and State laws relating to building construction Total Fee V LDMA Perm q i
R and hereb nze representatives of this County to enter `, 5
upon t above for inspection purposes
�d�Q SEE REVERSE FOR EXPLANATORY LANGUAGE
'gnature of A phcant or Agent - Date