HomeMy Public PortalAbout5226AGNES AVE_Building (9) VORKERS' COMPENSATION DECLARATION
1
,• that I have certificate of consent to Self R
t certificate•of Workers' Compensation Insurance, AP,PLIGOBUILDING PERMIT
or a cert cd copy tnereof'(Sec.'3800, Lob. C.) '
11 COUNTY OF'LOS ANGELES BUILDING AND SAFETY
Policy Na. Company %f
Certified ropy is hereby furnished. j FOR APPLICANT TO FILL IN, ADDRESS :22 , , 6
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS rr7ee,,L ,� CJN V`
Date Applicant CITY GI`r'` i , a ZIP J 7 Oaa
D, r,~; LOCALITY 1
CERTIFICATE OF EXEMPTION FROM WORKERS' - lJ/� 1 ;- NO:;OF BLDGS. ;� NEAREST
COMPENSATION INSURANCE SIZE OF LOT /fv~ / NOW'.ON LOT'' .a, CROSS SL
I
(This section need not be'compleied if the permit is for one "+ ASSESSOR 1
hundred dollars ($100)or less.) TRACT: w BL�[Oj,C,.,K LOT'NTEL. /.�-� 7� MAP BOOK PAGE PARCEL I
OWNER /' n NO. G-p/ ' �li� USE NE MAP /
I certify that'in the performance of the work for which this N 61
O. —Z.�
permit is issued, I shall not employ any pe�it, any manner r ° a ` gDDRESS CONDITIONS
sods to become s�iubject to the Wor sCsation aws.J�^ Q ' CITY n ZIP f" I
i
Date Applicant ARCHITECT-OR /� TE f .
NOTICE TO APPLICANT: If, after akin this Certif tate of , DISTRICT GRJPYPEFIRE PROCESSED BY
g ENGINEER'• lj' NO. IST ``/' ONST._ Z E
Exemption, you should beta. e subject to the Workers' �JLf `1
Compensation provisions of the Labor Code, you must forth- _ ADDRESS�/ CJI `
with comply with such provisions or this permit shall 'Be TEL. STATISTICAL CLAS�jFI A710N APT. ONDO. f
deemed revoked. CONTRACTOR (� NO. �(�/
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS j
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.- i
(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
SO. FT INC. OF NO. OF :CHECK BK. �/ PG. _
License Number Lic.Class SIZE STORIES FAMILIES ONE
;W 0 VALUATION9 3 3
Contractor Date DESCRIPTION OF WORK AD ; / * 0 0 0.0
I am exempt under Sec. ` S� �d �. if ���JJJ t ej
• ALTER
B.&P.C. for this reason AA0 e'eeX REPAIR 0 $ G J
Date: USE OF
G
EXISTINBLDG. DEMOL ❑ !
Signature APPLICANT TEL. FINAL . !
OWNER-BUILDER DECLARATION PRINT /� NO. �J iL
DATE T
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): FREbENI ByBU MING
/V
I, as owner of the property, or. my employees with ADDRESS
wages as their sole compensation;will do the work and
LOCALITY F
the structure is not intended or offered for sale(Section 9723 !�
7044, Business and Professions Code). MOVING TEL,
I, as owner of the property, am exclusively contracting CONTRACTOR NO. # o 0 0 0 .0 1 1
with licensed contractors to construct the project (Sec- - c /L 7
tion 7044, Business and Professions Code), ADDRESS `
REQUIRED. TOTAL BACK
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pap; LINE WIDTH , ,' ^ o �! Q,? z
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. "t, " ` a3 1 = 1
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name i
�® -f r LDMA Ref�ff
.7
m Lender's Address P.C. Fee$ Permit Fee
1 certify that I have read this application and state that,the Issuance Fee' `J ff LDMA P/C ii
o above information.is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating.to building construction, ``"
N Total Fee q LDMA Perm.,N
and hereby outhori epres ntatives of this County to enter
a upon th above- nti ned roperty for inspection purpos s.
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SEE REVERSE FOR EXPLANATORY LANGUAGE
a I
ignature Applicant'Or Agent Date