HomeMy Public PortalAbout5728AGNES AVE_Building (4) ENSATIONrDECLARATION T
a�„ R;;, have 0-certificate of consent to self '*'y'O o m -
l'tsucF --� certificate of Workers' Compensation Insurance ': :'^x. ,, �' �� \
APPLLCA N' F R �BUILDtNC� P RMIT
o�o certified-copy thereof (Sec. 3800, Lab.'C.) c -- --
- • ' COUNTX'OF LOS ANGELES BUILDING AND SAFETY
Policy No: _ Company c a. :- - -- - ---- - - - -
-.Certified copy,is hereby:furnished r _ FOR APPLICANT TO FILL IN BUILDING sem'
Certified co is filed with the*count*county, ldtn inspec- '- "- PICU" V
ADDRESS
pY Y 9 p BUILDING
ADDRESS Z S A Cr N t $ k V
a, tion department;
r' `� V
Date'' Applicant J CITY M L V 1.+ I-*T'Y ZIP 1 LOCALITY
CERTIFICATE'OF'EXEMPTION FROM WORKERS `'it, -- - --- ----------- - - NO.OF BLDGS- NEAREST.--_ -
-- COMPENSATION'INSURANCE -•- SIZE OF LOT NOW ON LOT - CROSS,ST.,_..
(This section need,not.be completed if the••permit'is for-one -- - -- -' ASSESSOR._,, ^" "' -
hund_red dollars ($100) or.less.) TRACT q M--M'
LOT NO. MAP BOOK' 1 ;!PAGE PARCEL
TEL.�. 'OWNER-M' .--'-�r-'-M--M' I � - NO. -- -.._. 5 MAP ;
I certify that in the perfor` nce of the work for which this NO.
USE ONE
permit,s issued I'shall not oy bny.person in any manner ^ Q A o -SPECIAL-t. -- , - -- - -- - - O
so as`to cb esu IecY'to The orkers'Compe" on',,Laws..
-ADDRESS-5,- l 'Y A^G N-y S- fv- -• CONDITIONS
U
/_ _ _.- CITY, ._,F. . .-PLO, , ._ ._. IT-1--ZIP
_-ZIP__ _ __ _______.._ t __ 1 OC
Date,6 ✓6' _APP T
ENGINEERARCHITEC�T N J o_H.N S o N No.33_I bg3g _ � o
NOTI E'T APPLICANT If, 'a`fterYbi
g C tificate of • DISTRICT GROUP' TYPE FIRE PRED BY _
Exemption, you should becomeje t'to t e�-•Workers' "- 1 ST ZONE / �jCom ensation rovisions of'lthe LC ou must;farth- �
P P ADDRESSZ V O G d V 1 NA H 1 LLS R 0 • y
with comply,with <such, provisions or.this permit shall be -- _ _. -.. ..-__,^ _. fCON
--
L STATISTICAL CLASSIFICATION T. C DO.
deemed revoked.-• z, a :. CONTRACTOR " NO. _ (j
-'.
LICENSED CONTRACTORS DECLARATION• , __._ _-___- __. ,_.._- ___LIC __ _... __ _CLASS NO. DWELL. UNITS
I,hereby affirm that.I am licensed under provisions of Chapter 9 ADDRESS NO. I
(commencing with Section7000)-of Division 3 of the Business _.- _. __ -_ ..LIG.-' -- SEWER MAP
Professions-Code,'and-my license is,in full force and effect. CITY CLASS VALIDATION
SQ. FT NO. OF NO. OF. _ _CHECK -
BK. PG.-
a1 - SIZE STORIES _ FAMILIES .. - ONE } _,
License Number 6c.Class
_ . -
DESCRIPTION OF'WORK YD'�1'�,�7 ': - NEW O
` • ,- VALUATION.
Contractor Date
ADD $
1 am exempt under Sec - �%Yt•S.l Q, "��._�r_� ;._�.I^�.�/�-- ALTER -. __ ..__- -
--- -11� i`- 5 R C S I P&V G6 _s - - – ,• 9 ?; A-
B.&P.C. for this reason ._ _ REPAIR " ! Z
- USE OF
.._...Date:' _._ �.t
EXISTING BLDG. �• F# R S • DEMOL __--- ff•o-o o.-.o 23, _
APPLICANT T -_. - -- - _
Si'nature --
g OWNER-BUILDER DECLARATION PRINT)k N N T H G.J RISC FINAL
,,.-„ DATE- � � , ._( of g
I-hereby affirm that 1 am exempt from the Contractors License Z 0?e'7 GO V^�• - HJk L P.
Law for the followingr'reaso`n-(Section 7031.5, Business and ADDRESS FIN _;
Pi"ofe-"ons'Co`de) "" PRESENT EI' BUILDING 2
as owner of the property, .or myemployees with - ADDRESS. _ _ _ ___ _ _ .. _.. _. Ul . - - T! ' - ✓ Q C/,1J
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. ;
^with licensed^contractors'to'construct the project(Sec-
Tion 7044, Business and Professions Code). ADDRESS _
_-REQUIRED_ TOTAL SETBACK_FROM _.- EXIST.
"CONSTRUCTION LENDING-AGENCY - SET BACK YARD` '-HWY-""' - PROP. LINE WIDTH - c-"_� 1 1,0-A
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-.,-
(Sec.
--
(Sec. 3097, Civ. C.). SIDE
m P.L. --" I o
_ -- _
i
4 7 �.•7'5
Lender's Name t
o LDMA Ref. # 1:
m _ P.C-Fee-$ _. _..-. s 0..,. Permit Fee �_.., t
Lender's Address - t
I 1�6
I.certify-that._1 have read-this.application and-state that.-the Issuance-Fee- / � - LDMA P/Gz#4 = f' 'T-= ` - -
a above information is correct. I agree to comply with all County Investigation Fee s
ordinances and State laws relating-to building construction, Total Fee - -- -
_ - _- _ 7 .� _.. <LDMA Perm:#-
d and hereby authorize representatives of this County to enter
f u on the above-mentioned property for inspect7urposes.G S SEE REVERSE FOR EXPLANATORY LANGUAGE
..._.Si ure�li ant or-Agent -_ DjKie .. _._ _;._._....-- — - --- -'• -. _ _ _. _ -•-- -- ... .__.� .. ___._._..- -- -..__• _ --• -- --_ . ._.