HomeMy Public PortalAbout5234AGNES AVE_Building (6) j WORKERS COMPENSATION DECLARATION
,.urb affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT
•�t5ure or a certificate of Workers Compensation Insurance .. -
or a certified copy thereof (Sec 3800 Lab C ) _ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company r
BUILDING
{Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS
E] {C
❑ Certified copy is filed with the county building inspec BUILDING
tion department ADDRESS
G•�
Date `Applicant CITY G/� lam/T ZIP 60 LOCALITY / ti
NO OF BLDGS NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT O / f� NOW ON LOT CROSS ST ti
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL
hundred dollars ($100)or less ) A TEL
" OWNER � �� C W4 NO _ USE ZONE INO
AP
I certify that in the performance of the work for which this Y l/ 1 SPECIAL - >-
permit is issued I shall not employ,any person in any manner ADDRESS S >'e3 r " A 1CONDITIONS a
so as to become subject to the Workers Compensation Laws CITY C/T ZIP "F 7dD O
Date Applicant ARCHITECT R TEL DISTRICT GROUP TYPE FIRE PROCESSED BY 0
NOTICE TO APPLICANT If after makingthisCertificate of ENGINEER NO CONST Z NE C
Exemption you should become subject to the Workers t JW r w
Compensation provisions of the Labor Code you must forth ADDRESS GGEd- � a
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO N
deemed revoked CONTRACTOR L� ory*�u-eJ NO ?
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS
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
and Professions Code and my license is in full force and effect CITY CLASS BK PG VALIDATION
L SQ FT/ y NO OF / NO OF CHECK
License Number Lic Class SIZE /� 3 STORIES / FAMILIES ONE
VALUATION
DESCRIPTION OF WORK Dp NEW El $ UU 7,
Contractor Date , _
S y ADD ❑
❑I am exempt under Sec
+ ALTER ❑ � .. ..
B&P C for This reason S j REPAIR ❑ $
USE OF
r� Dater EXISTING BLDG DEMOL ❑
Signature APPLICANT
T ��� TEL p
����'� NOp�6�-� r�i- FINAL q
OWNER BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and ADDRESS FINAL t
Professions Code) PRESENT _ _ - By Ff
BUILDING ACCT 8
El as owner of the property or my employees with ADDRESS ,�
wages as their sole compensation will do the work and - _ ► - - - _.%-J0! 93,t�7
the structure is not intended or offered for sale(Section LOCALITY ITEM-:i 7044 Business and Professions Code ) MOVING _ TEL 1 1TEt -:
❑ I as owner of the property am exclusively contracting CONTRACTOR NO _ r � 3
with licensed contractors to construct the project (Sec ADDRESS ANAL ® '
tion 7044 Business and Professions Code ) HECK 5�doiL
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH ` ('�
I hereby affirm that there is a construction lending agency for FRONT r�� �]G a Le I
the performance of the work for which this permit is issued P L _
(Sec 3097 Civ C ) SIDE
PL
Lenders Name t
LDMA Ref # t } �{i ii
' t PC Fee$ ' Permit Fee ?C7�rie 1 Fhi1y:Le
Lender s Address
o j certify that I have read this application and state that the Issuance Fee � 75 LDMA P/C#
o
Poo.—
above information is correct I agree to comply with all County i Investigation Fee i
ordinances and State laws relating to building construction I Total Fee LDMA Perm #
a and herebyy,��authorize r9presentatives of this County to enter
upon the above men rt.ned property for inspection urposes -
�) SEE REVERSE FOR EXPLANATORY LANGUAGE i
Signature of Applicant or Agent ate