HomeMy Public PortalAbout5729AGNES AVE_Building (2) WORKERS COMPENSATION DECLARATION ' 0,
hereby affirm that It have a certificate of consent to self APPLICATION �FOR BUILDING PERMIT �
insure or a certificate of Workers Compensation Insurance
or a certified.co thereof j(Sec 3800 Lab C )_
PdT,c�No /° �! Eompany ��.7lC.C� COUNTY OF LOS ANGELES BUILDING'AND SAFETY
BUILDING `�J
Certified copy ,s hereby furnished FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec BUILDING
tion department ADDRESS LOCALITY k
1NEAREST
Date Applicant CITY x, ZIP CROSS ST dL
CERTIFICATE OF EXEMPTION FROM WORKERSNO 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 F USE ZONE MAP �7
hundred dollars ($100)or less ) TRACT BLOCK LOT NO ` NO /
r r TEL F 1 SPECIAL }
I certify that in the performance of the work for which this ` OWNER N CONDITIONS CL
permit is issued I shall not employ any person in any manner r-
DISTRICT GROUP ITPE FBY O
Y
so as to become subject to the Workers Compensation Laws ADDRESS CONST ZIRE PR SSED ONE V
99
Date Applicant CTITY �,_ ZIP STATISTICAL CLASSIFICATION APT CONDO 0
NOTICE TO APPLICANT If after makingthis Certificate of ARCHITECT OR TEL �1� V
Exemption you should become subject to the Workers ENGINEER NO CLASS NO DWELL UNITS d
Compensation provisions of the Labor Code you must forth ADDRESS ^ SEWER MAP t 4A
with comply with such provisions or this permit shall be �//
deemed revoked CONTRACTOR p BK Pc�/ '�" VALIDATION
a LICENSED CONTRACTORS DECLARATION LIC R y
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NQ3 / VALUATION
(commencing with Section 7000)of Division 3 of the Business and //�� LIC C<
Code and my license is in full force and effect CITY 64 G- CLASS $ C7V (J
SQ FT NO OF NO OF CHECK ,
Lcerise Number 3P4/ �a7 Lic Class a SIZE STORIES FAMILIES ONE
(CP,rofessions
onlractorJ�Z/ll��� 'V (�-Jf� ate NEW ❑ $
DESCRIPTION OF WORK
I am exempt under Sec ADD C1t - ,+ A
y ALTER ❑ DATE g?
B 8P C for this reason REPAIR ❑
Date USE F DEMOL FINAL ���� 9 5 6 9 8 A
EXISTING BLDG ❑
Si nature APPLICANT w TEL By y
g OWNER BUILDER DECLARATION PRINT NO /-� # 0 0 0 0 0 1
I hereby affirm that I am exempt from the Contractor s License ADDRESS ► `O 2 0 11550
Law for the following reason (Section 7031 5 Business and
Professions Code) PR NTYa 0 1 1 6 5
7 BUILDING 0 Q
I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and LOCALITY r 09 30-83
the structure is not intended or offered for sale(Section
7044 Business and Professions Code) t MOVING TEL
❑ I as owner of the property am exclusively contracting CONTRACTOR NO `
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code)
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH
I hereby affirm that there,s a construction lending agency for FRONT
the performance of the'work for which this permit is issued P l
(Sec 3097 Civ C ) SIDE
m
PL '
v Lender s Name ,
$ Lenders Address ` k P C Fee S y Permit Fee 1
c
I certify that I have read this application and state that the Issuance Fee / a
above information is correct I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction Total Fee
C{ and hereby authorize representatives of this County to enter
u�tve mentio property f pection purposes
^ h i SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Ap scant or Agen Dote—/015F ®s
1