HomeMy Public PortalAbout5128AGNES AVE_Building (4) r
COMPENSATION DECLARATION a
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t I have a certificate of consent to self r APPLICATION F®RBUILDING PERMIT
A ;
ate of Workers Compensation Insurancehereof (Sec 3800 Lab C ) ' t COUNTY OF LOS ANGELES BUILDING AND SAFETY
Company t
Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING
ADDRESS
II Certified copy is filed with the county building inspec BUILDING T ''
tion department ADDRESS ' y.
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Date Applicant CITY [� ZIP Q_ LOCALITY
CERTIFICATE OF EXEMPTION ROM WORKERS - NZ5 OF BLDGS - - i r NEAREST
:COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST ZlY
•,r ; (This section need not be completed if the permit is for one TRACT " t BLOCK y LOT NO f ASSESSOR �pg� �7
r hundred dollars ($100)or less ) MAP BOOK ) ' PAGE 00 J PARCEL
OWNER m r NO � 2 USE ZONE MAP
i" I certify that m the performance of the work for which this � NO '
permit is issued I shall not employ any person m any manner a ,�� SPECIAL
so as to become subject to the Workers Compensation L s ADDRESS CONDITIONS ^
f R
CITY ZIP lJ
Date APIC
licont
NOTICE TO APP (CANT If 'after making this Certificate of ARCHITERT OR NO DISTRICT GROUP ONST ZONE PROCESSED BY O
y r Exemption you should become subject to the Workers ENGINE
Compensation provisions of the Labor Code you must forth ADDRESS
with comply with such provisions or this permit shall be - TEL STATISTICAL CLASSIFICATION APT CONDO Cn
deemed revoked CONTRACTOR NO ~
Z
'LICENSED CONTRACTORS DECLARATION LIC- CLASS NO DWELL UNITS a
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
} r Professions'Code and my license is in full force and effect CITY CLASS BK VALIDATION
f " SQ FT 1 NO OF NO OF _ CHECK
PG
License-Number Lic Class SIZE STORIES FAMILIES ^ ONE ,
` a e VALU TION
ADD $
Contractor Date DESCRIPTION OF WORK ❑
❑ I om exempt under Sec cS
,+ ALTER I ,
B&P C for this reason REPAIR ❑ $ '
J Date USE OF DEMOL ❑ 9 2 0 5 A
EXISTING BLDG
Signature j
g APPLICANT - ' TEL FINAL 3- - # • • • e e � 1
PRINT / L �NO �Z
OWNER BUILDER DECLARATION DAT
I hereby affirm that I am exempt from the Contractor s License s p E,141,196'
Law for the following reason (Section 7031 5 Business and ADDRESS Sl2 $�T�t/V�S f}lrL /• <+ FIN I • - 4988
Professions Code) t P _;
` BUILDING ^ Y • • •T4 9 8 8
Er I as owner of the property or my employees with ADDRESS '
wages as their sole compensation will do the work and ® 0'a 1 9r--8 8
r the structure is not intended or offered for sale(Section LOCALITY
s 7044 Business and Professions Code) MOVING TEL z
❑ 1 as owner of the property am exclusively contracting CONTRACTOR Y NO
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code)
'
CONSTRUCTION LENDING AGENCY r - SET BACK REQUIRED YARD HWY TOTAL SETBACK FROM
PROP LINE WIDTH
Ihereby affirm that there is a construction lending agency for FRONT e
the performance of the work for which this permit is issued P L
A
(Sec 3097 Civ C ) � SIDE
� t P L
Lender's Name 7 LDMA Ref #',
P C Fee$ Permit Fee
Lender s Address
7
I certify that I have'reod this application and state that the Issuance Fee LDMA P/Ct#
ation Fee
o above information is correct I agree to comply with all County Invest, ee
0 org
ordinances and State laws relating to building construction ! w Total Fee �g v
o LDMA Perm q
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and hereby authorize repre entahves of this County to enter
upon the lov:Ao ed troperty for inspection purposesa 13 P1 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date