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HomeMy Public PortalAbout5123AGNES AVE_Building (6) WORKERS COMPENSATION DECLARATION I hereof consent to insure affirm a certtf carte of Worke srtComtpensation Insurancef APPLICATION FOR BUILDING PERMIT _ or a certified copy thereof (Sec 3800 Lab C ) I ` / z '4 T BUILDING AND SAFETY Policy No.�a!&/ Company 13 � COUNTY OF LOS ANGELES &0�0 r ~ BUILDING ~ Certrfted copy is hereby furnished FOR APPLICANT TO FILL IN - ADDRESS 7—3 /tliS ❑ Certified copy is filed with the county building inspec BUILDING /� -- tion department ADDRESS E , M /� L DateR�� _13 r +Applicant L.., + CITY � i 1� (� i ZIP, �C7 L s LOCALITY N OF BLDGS NEAREST c CERTIFICATE OF EXEMPTION FWORKERS SIZE OF LOT NOW ON LOT CROSS ST " COMPENSATION INS NCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL hundred dollars ($100) or less ) - TEL j - t + OWNER / S �- NO USE ZONE OP a � I certify that in the performance of the work for which this ,✓ _ IAL permit is issued I shall not employ any person in any manner ADDRESS A/( - YT CONDITIONS 0- so as to become subject to the Workers Compensation LawsO 5 �� C/ ZIP U t CITY Date Applicant* ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PRO ED BY O NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO 0 CONS ZO Exemption you should become subject to the Workers ©� � a Compensation provisions of The Labor Code you must forth ADDRESS u i with comply with such provisions or this per shall be , - / .�• TEL STATISTICAL CLASSIFICATION APT C O Z deemed revoked CONTRACTOR W / / /e/ NO 7 1 - _ LICENSED CONTRACTORS DECLARATION ADDRESS O �` L� LC a3f CLASS NO DWELL UNITS— LICENSED I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 ofithe Business LIC and Professions Code andimy license is in full force and effect CITY ( 0 /2 Pl'/ CLASS G BK PG VALIDATION SQ FT' NO OF NO OF CHECK _ License Number q Q 3-17 7 `Lc Class 6N SIZE pC STORIES FAMILIES ONE r VALUATION `2 DESCRIPTION OF WORK (L NEW ❑ Contractor L(Llt%�GJ /'1��?�/ate -3 $ ElI am exempt under Sec O c /V /?o O loop.❑ //++ ALTER ❑ B&P C for this reason `' �© �b REPAI $ r' � D u5 O M u _ EX STING BL DEMOL ❑ Signature 0 APPLICANT TEL FINAL OWNER DECLARATION (PRINT) NO DATE I hereby affirm that I exempt from the Contractor s License _ _ r Law for the following reason (Section 7031 5 Business and ADDRESS FINAL --'- Professions Code) PRESENT_ _, _ By - ❑ I as owner of the property or m employees with BUILDING Y " __ P P Y YADDRESS wages as their sole compensation will do the work and A1C fit the structure is not intended or offered for sale(Section LOCALITY , + 7044 Business and Professions Code ) MOVING TEL CONTRACTOR NO I as owner of the property am exclusively contracting - with licensed contractors to construct the project (Sec ADDRESS tion 7044 Business and Professions Code ) REQUIRED.. YARD HWY TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK PROP LINE WIDTH y 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 r (Sec 3097 Civ C ) s SIDE ' Lender s Name z O LDMA Ref # a P C Fee L Permit Fee , Lender s Address , o r I certify that I have read this applcation and state that the Issuance Fee LDMA P/C# ` 8 above information is correct I agree to comply with all County Investigation Fee �J r ordinances and State laws relating to building construction Total Fee 7 LDMA Perm # e and here authorize representatives of this County to enter - upon the ove mention$ property f inspection purposes r ` / J l� SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur plicant or Agent Date -