HomeMy Public PortalAbout5729AGNES AVE_Building WORKERS COgfPENSATION DECLARATION /
hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure or a certificate of Workers Compempenstion Insurance or
a certified c�jp S.,e.(Sy�of� Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
licy o N G om/p/a�n�y
Po � BUILDING
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the count building inspec BUILDING.
tion deportme t t ADDRESS LOCALITY
�-y NEAREST /,/�
Date Applicant_/2&��� CITY r/ ZIP CROSS ST v 1
CERTIFICATE OF EXEMPTION FROM W KERS NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT - MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE [MAP .^�TRACT BLOCK LOT NO O O� a Q /hundred dollars ($100) or less �J 11TEL /� ECIALcertify that in the performance of the work for which this OWNER —J NO � ONDITIONS O
permit is issued I shall not employ any person in any manner~ �>
DISTRICT GRO TYPE FIRE PR SSED BY U
so as to become subject to the Workers Compensation Laws ADDRESS r /�' +C 0� ONST Z O
I
-Date Applicant CITY ZIP STATISTICAL CLASSIFICATI N APT CONDO V
ARCHITECT OR TEL I
NOTICE TO APPLICANT If after making this Certificate of ENGINEER "�� NO /` IW
Exemption you should-become subject to the Workers CLASS NO DWELL UNITS y
tCompensation provisions of the Labor Code you must forth ADDRESS 1 SEWER MAP z
with comply with such provisions or this permit shall be
deemed revoked TEL BK PG �l Z VALIDATION
CONTRACTOR NO
LICENSED CONTRACTORS DECLARATION LIC U6
+ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO A P /� t VALUATION
(commencing with Section 7000)of Division 3 of the Business and / I
Professions Code and my license is in full force and effect CITY N �{�/ CLASS $ j96
SQ FT NO OF NO OF CHECK
*License Numb r Lic Class SIZE STORIES FAMILIES ONE
$
Contractor Date DESCRIPTION OF WORK r NEW ❑
+ Im exempt fr the licensing requirements as I am a ` S ADD
// ❑ `
licensed architect or a registered professional engineer ALTER ❑ DATE
y
9 P 9 i I - ❑ C ""7
x
acting m my professional capacity (Section 7051 � REPAIR DATE
Business and Professions Code) USE OF FINAL
DEMOL
1 EXISTING BLDG ❑ By 6--�'��a-•C.�
Lic or Reg No Date APPLICANT TEL
r OWNER BUILDER DECLARATION (PRINT) NO
f hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and t ADDRESS
Professions Code) PRESENT
BUILDING
❑ t I as owner of the property or my employees with ADDRESS ^
wages as their sole compensation will do the work and /
the structure is not intended or offered for sale(Section LOCALITY s
,
7044 Business and Professions Code) r MOVING TEL J-_1 2 2 2 9 A
F7I as owner of the property am exclusively contracting CONTRACTOR NO _ # 1
with licensed contractors to construct the project (Sec ADDRESS
o o e s o
tion 7044 Business and Professions Code) - y f
REQUIRED TOTAL SETBACK FROM EXIST a t 2 • e 976 0
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT '010 0 9 7 0 0=a:
the performance of the work for which this permit is issued P L
(sec 3097 Civ C ) _ SIDE 12 0"9—8 1 r,_PL
—
Lender s Name
T �0
P C Fee$ Permit Fee }
� Lender s Address "
? I certify that I have read this application and state that the Issuance Fee .S
aboveinformation corre t I agree to comply with all County Investigation Fee
ordinances St e I s relatin to building construction Total Fee 06 ~
and hereb a th ize epresent es of this County to enter ' s
U
upon'the b e ioned pr ty for inspection purposes
-
d
� SEE REVERSE FOR EXPLANATORY LANGUAGE
ig ature o plimnt or Ag nt Date + Oo s