HomeMy Public PortalAbout5227AGNES AVE_Building (10) WORKERS' COMPENSATION DECLARATION
ent to sf
insu'a,oraa certif catte of Workers' Comtpennsat on Insurance, .- APPLICATION FOR BUILDING P ERM I T
or a certified copy thereof (Sec. 3800,Lab. G.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company ?
EJCertified copy is hereby furnished. `FOR APPLICANT TO FILL IN - ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING .5
tion department. ADDRESS
CITY C/// 1� C��r ZIP /
LOCALITY
Date Applicant NO. OF BLDGS.
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT
CROSS ST.
COMPENSATION INSURANCE ASSESSOR ,) n yf
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK T PAGE VV PARCEL V i
hundred dollars ($100) or less.) l /�J, / /�SEL n v
OWNER' ^,19't,�{f (34C1�' ��(//NO a� J'�G d USE ZONE MAP
I certify that in the performance of the work for which this n _ �� NO.
P employ Y P Y / a��/L/`�� N+ SPECIAL CL
permit is issued, I shall not em to an person in an manner ADDRESS CONDITIONS
so as to become subject.to the Workers'Compensation Laws. �� (j/ O
CITY /z/ '� G✓ 7 ZIP 7/ U
Date Applicant ARCHITECTORe& �� TEL. DISTRICT GROUP TYPE FIRE PROCESSED.BY 0'
NOTICE TO APPLICANT:'If,•after making' this Certificate of ENGINEER. ( �+�� NO. CONST. ZONE
Exemption, you should become,subject to the Workers'
�j
Compensation provisions of the Labor Code, you must forth- ADDRESS ® ✓ ✓ -C N
With comply with such provisions or .this permit shall be //yam fJ T �- STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR , ✓U �`�`�� A% • �/ DWELL. UNITS
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.
1 I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �� NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
s j and Professions Code,and my license.is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
`j License Number Lic. Class SIZE STORIES FAMILIES ONE
- VALUATION
DESCRIPTION OF WORK NEW ❑
Contractor Date � /U� ADD $
❑I am exempt under Sec.
ALTER ❑
B.&P.C. for this reason �/ p // / �c^ REPAIR ❑ $
USE OF
Date: EXISTING BLDG. ��/y Ile CZ,<� DEMOL ❑
Si nature APPLICANT y� a
g OWNER-BUILDER DECLARATION (PRINT). /+ G-�C/��//��L` O. DA EL, ^Q
1 hereby affirm that I am exempt from the Contractor's License '
Law for the following reason (Section 7031.5, Business and ADDRESS . FINAL ,
Pe.10fossions Code): PRESENT BY
1, as owner of theproperty, or m employees with BUILDING Ff!__• =a
YADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
❑
7044, Business and Professions Code.) MOVING TEL. _
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
f. � —.��•
with,licensed contractors to construct the project (Sec- ADDRESS . ?� 2 _r
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST:
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTHr.
I hereby affirm that there is a construction lending agency for FRONT t-• ri�13i_
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name.
LDMA Ref. # F.+,
P.C. Fee$ Permit Fee T` 'd!' is -'»% ks r4 J W.
Lender's Address
_ r s
I certify that I have read this application and state that the Issuance Fee s' LDMA P/C# ►
above information is correct. l agree to comply with all County Investigation Fee //� �+ �f r'
ordinances and State laws relating to. building construction, Total Fee ! �" ✓ ' 5 LDMA Perm. #
and emby authorize representativ s of this County to enter
u o bove-mepKqA&d pro y for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date