HomeMy Public PortalAbout5117AGNES AVE_Building (9) ,t
r WbRKERS COMPENSATION DECLARATION
in urebor a certif cat.I ofaWorkers have a rtificate of Compensat on Insuran nt to of - APPLICATION FOR BUILDING PERMIT
or a certified copy there-)f (Sec 3800 Lab C ) `
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
BUILDING
Certified copy is hereby furnished FOR APPLICANT TO FILL IN
ADDRESS J�71
❑ Certified copy is filed with the county building inspec BUILDING
tion deportment r ADDRESS r,
Date/' 2✓ Applicant CITY / t ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE i SIZE OF LOT NOW ON LOT CROSS ST
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less ) TRACT I BLOCK LOT O MAP BOOK I PAGE PARCEL
TE O USE ZONE MAP
I certify that in the performance of the work for which this OWNER �/� tt/t r TN Z- �//� NO
permit is issued I shall not employ any person in any manner ADDRESS��/ ,/YCSS I/ i r SPECIAL O
so as to become subject to the Work o s C CONDITIONS
CIV
Dat 2S Applicant TY ZIP �
NOTICE TO APPLICANT If aft making t is Certificate OR TEL
DISTRICT ate of GggqQQQUP I TYPE FIRE PROCESSED BY 0
Exemption you should become subject to the Workers ENGINEER NO // CONST ` ZONE U
Compensation provisions of the Labor Code you must forth ADDRESS
with comply with such provisions or this permit shall be
deemed revoked TEL STATISTICAL CLASSIN ATION APT CONDO N
CONTRACTOR NO Z
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 VALIDATION
SQ FT NO OF NO OF CHECK BK PG
License Number Lic Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW O $
❑ 01 ADD
I am exempt under Sec R��Q : v lit/ V v
f ALTER � ,
B 8P C for this reason I REPAIR ❑ $
USE OF ❑
Date EXISTING BLDG DEMOL 92 4 5 A
Signature APPLICANT TE FINAL ,8 8 a,9 8%
OWNER BUILDER DECLARATION PRINT t NO DAT
I hereby affirm that I am exempt from the Contractor s License * e o 49 886
ADDRESS
Law for the following reason (Section 7031 5 Business and FI 03.25-88
Professions Code) "
❑ 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 CONTRACTOR NO
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code)
REQUIRED TOTAL SETBACKz _
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
PL
Lender s Name
2 LDMA Ref #
Lender s Address P C Fee$ Permit Fee ,J
31
I certify that I have read this application and state that the Issuance Fee LDMA P/C#
oabove information is correct I agree to comply with all County Investigation Fee Q
0 ordinances and State laws relating to building construction Total Fee 0 LDMA Perm #
R a�h �uth �re�otives of this County to a ter
uperty"for inspection
'Pu es
' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat a of Applicant or Ag Date