HomeMy Public PortalAbout5226AGNES AVE_Building (2) WORKERS' COMPENSATION DECLAk?,TION II
hereby affirm that I have a certificate oself
insure, or a certificate of Workers'Compenstion Insuronce,'or
APPLICATION- F O Rt BUILDING PERMIT
a certified copy litSS /
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� � 46
Certified-copy is filed'with the county building inspec- BUILDING _
tion'department-. ADDRESS <��l - ,: A)�S A L t LOCALITY 1
• t - NEAREST
Date Applicant CITY ?' G�i GrP' zip -7 CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' , NO. OF BLDGS. ASSESSOR
- COMPENSATION INSURANCE SIZE OF LOT /60 /,3 NOW ON LOT - 3 MAP BOOK PAGE PARCEL
(This section need not be completed if the.permit is for one USE ZONE MAP
TRACT BLOCK LOT NO. 7_
hundred dollars ($100)or less.) TEL �/ ECTAL
I certify that in the performance of the work for which this OWNER �/pfi�/V�� /$T✓I NO. ONDITIONS Q
n GROUP TYPE FIRE PR0056SED BY (J
permit is issued, I shall not employ any person in any manner �� CONST. ZO
S
so as,to become subject to the Workers'Compensation Laws. ADDRESS /L7- .96A)E Ad
NE
CITY, -7-6M gae e Gr W7 ZIP 1763 p'
Date Applicant STATISTICAL CLASSIFICATION APT. CONDO. (,
NOTICE TO APPLICANT: If, after makingthis Certificate of ARCHITECT OR TEL. t0.
Y
. ENGINEER J'. NO. CLASS NO. DWELL. UNITS
Exemption, you should become subject to .the Workers' N
Compensation provisions of the-Labor Code; you must forth- ADDRESS SEWER MAP
with-comply with such provisions or this permit shall be _ TEL.; VALIDATION +
deemed revoked. CONTRACTOR 01 3K 6PG,7
'LICENSED CONTRACTORS DECLARATION LIC.
I hereby offirm'that I am licensed under provisions-of Chapter 9 ADDRESS VALUATI y�
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code, and my license is in full force and effect. CITY CLASS $
SQ. FT. NO. OF NO. OF CHECK
License Number Lic.Class SIZE (p STORIES / FAMILIES / ONE
Contractor Date DESCRIPTION OA�F!/WORK NEW
. �.•' Tj�} fJGt�ij ADD
0 lam exempt from the Licensing requirements as I am a
licensed architect or a registered professional engineer ALTER ❑ FINAL
acting in my professional capacity (Section 7051; REPAIR ❑
DATE
Business and Professions Code). USE OF
FNAL
DEMOL
EXISTING BLDG. ❑ BY i' f
Lic.or Reg. No. - Date APPLICANT TEL.
OWNER-BUILDER DECLARATION (PRINT) ��i4+t1lC O/¢7rU No.o '— /7
I •ereby affirm that I am exempt from the Contractor's License
L _ for the following reason. (Section 7031.5, Business and ADDRESS
P fessions Code): PRESENT
BUILDING -
I, as owner of the property, or,my employees with ADDRESS
wages as their sole compensation,will do the work and
LADDR
Y
the structure is not intended or offered for sale(Section 2 1 �i'' J,5 A
7044; Business and Professions Code). G TEL.
❑ CTOR NO.
I, asownerof the property, am exclusively contracting r;e o.0 0 0 �
with licensed contractors to construct the project (Sec- S
tion 7044, Business and Professions Code). 2 o o 4 3, r O
IRED TOTAL SETBACK FROM EXIST:
CONSTRUCTION LENDING AGENCY CK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for T o o c ,' (J 0
the performance of the work for which this permit is issued
(Sec.•3097, Civ. C.). ( �, 1 I
Lender's Name
.m e$ Permit Fee
Lender's Addressw1 certify that I have read this application and state that the Issuance Fee
above information is correct. I agree to comply with all County ation Fee
0 ordinances and State laws relating to building construction, Total Fee
and hereby authorize representatives of this County to.enter
< upon the above-mentioned property.for inspection purposes.
m
SEE REVERSE FOR EXPLANATORY LANGUAGE
5S
Signature of Applicant or Agent Date