HomeMy Public PortalAbout5219AGNES AVE_Building WORKERS' COMPENSATION DECLARATIOI`
I hereby affirm that I have a certificate of conseh ro a
insure, or a certificate of Workers' Compensation Insurance, AtePLICATI0N FOR BUILDING PERMIT
or a certified copy thereof(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
❑ Certified copy is filed with the county building inspec- BUILDING -52 C�l�1� AV
tion department. `r ADDRESS _ lel h A i5 LOCALITY
Gy NEAREST
Date Applicant CITY i
�N h�=u.,' CI i � ZIP / /7 � CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. l' ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT 5 J� 1421 NOW ON LOT 0 4-z- MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one, 2 USE ZONE MAP
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. J NO.
� TEL. 1 SPECIAL }
I certify that in the performance of the work.for which this ) OWNER F-0 ZA 6t:=-` P 1'IirsAOZ NO. � CONDITIONS �
permit is issued, I shall not employ any person in any manner -t STRICT GROUP TYPE FIRE PROCESSED BY 0
so as to beco agject to the Workers'Cpmpens ion Laws. ADDRESS i t"''i i= G Y �� CONST. ZONE
j 0
Date Applicanf `�� ' ( CITY ZIP STATISTICAL CL SSI CATIO APT. CONDO.
NOTIC TO PPLIIf, after mrmg this CertificaT of ;+ ARCHITECT OR TEL W
Exemption, you should become subject to the Wo ets'
ENGINEER NO. CLASS No._ 2:/ DWELL. UNITS
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall be TEL. '
deemed revoked. CONTRACTOR �Lv 1� � NO. BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC j �pO
Professions Code; and my license is in full force and effect. S CITY CLASS
SQ. FT. NO. OF NO. OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
$
Contractor Date _� DESCRIPTION OF WORK ON ViRT C1-Af2ACr NEW ❑
LT
j am exempt under Sec. ro IS i a0t, D AAD ER FINAL
B.BP.C. for this reason Aa :i h'-1 6"t - REPAIR Q DATE
Date: USE ;} C l D� DEMOL FINAU r r
EXISTING BLDG. K- �. -� FI 1 � ✓i s
By
Signature
APPLICANT TELL'"�i
OWNER-BUILDER DECLARATION PRINT NO. ® .
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS
rofessions Code): PRESET t ! G?
BUILDING
I, as owner of the property, or my employees with ADDRESS ' o n o o e 1
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY r ,
7044, Business and Professions Code). MOVING TEL. ° e C,
I, as owner of the property, am exclusively contracting j CONTRACTOR NO. ,
with licensed contractors to construct the project (Sec- o I U
ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST. t`
CONSTRUCTION LENDING AGENCY SET BACK YARD HwV PROP. LINE WIDTH. -- i
I hereby affirm that there is a construction lending agency for HRN j
the performance of the work for which this permit is issued.(Sec. 3097, Civ. C.).Lender's NameLender's Address Permit Fee
I certify that I have read this application and state that the Issuance Fee /40.
above information is correct. I agree to comply with.all County Investigation Fee 1 J�
ordinances and State laws relating to building construction, Total Fee /o �°'
and hereby authorize representatives of this County to enter
upon;a v_e-mentioned property for inspection rpos .
SEE REVERSE FOR,EXPLANATORY LANGUAGE
Sigr{ature of Applicant or Agent }e •et