HomeMy Public PortalAbout5733AGNES AVE_Building (2) 7 WORKERS'COMPENSATION DECLARATIQN -
hereby affirm that I have r certificate,of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,'
or a certi?ied copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING nn
ElCertifiedcopy is hereby furnished. FOR APPLICANT TO FILL IN' ADDRESSS7 3 ,Je_S /�(d r ,
❑ Certified copy is filed with the county building inspec- BUILDING1 -� /�
ADDRESS `7 33 ! C-S 4v-e /� �L� C'•,-_ `
tion department. ✓ � �
CITY /Gih?>JC �i7 ZIP l �� LOCALITY
Date Applicant NO. OF BLDGS. NEAREST /
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT I SOa NOW ON LOT ' CROSS ST. ` I rle <D;014
COMPENSATION INSURANCE OL LYJ ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. / MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) TEL.B i$
OWNER 1c7. ✓A�� NO. 24sfv; USE ZONE MAP
I certify that in the performance of the .work for which this _t NO.
permit is issued, I shall not employ any person in any manner ADDRESS a-I%J Q3 r , CONDITIONS O
so as to become subject to the Workers'.Co ensation Laws. U
c
CITY G.+K, G C L ZIP �7 ��
XDate �� Applicant RCHITEC OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after makingthis Certificate of �' S'Cli�� O
E NO. 4S 7�O`7�IS CONST. ZONE � (--
Exemption, you should become subject to the Workers' Z�� ���^ �� ZU fN rj�GU Q-3 � w
Compensation provisions of the Labor Code, you must forth- ADDRESS Y /- n.
with comply with such provisions or this permit shall be \ r TEL. STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR CJJ+J �� IS�A.�•t O. Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 0—/ DWELL. UNITS' 23
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP ACCI
(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 r-PG / A-- WLIDATION rye c
SQ. FT. NO. OF NO. OF CHECK TCM '-'a•k'=•
License Number Lic. Class SIZE `2:3 STORIES L FAMILIES ONE 1 T i GI 1S
VALUATION
Contractor Date
DESCRIPTION OF WORK NEW ® TOTAL 75.m 45
�
... /� ADD ❑ � r c
❑I am exempt under Sec. ► t5-5.4_t
ALTER El CHECK N
B.&P.C. for this reason REPAIR ❑ 00 CHAWE °� I
USE OF MO❑
Date: EXISTING BLDG. !
DEMOL G
Signature APPLICANT TEL. tCi7
"FINALV— �� vl:�rr
OWNER-BUILDER DECLARATION (PRINT) NO. = DAT{ �� °C•1d�
40
1 hereby affirm that I am exempt from the Contractor's License — '` 1 AM $•
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code):. PRESENT By n s
BUILDING At'�' °g
❑ 1, as owner of the property, or my employees with ADDRESS �- 76.50
wages as their sole compensation,will do the work and 3OOr'
the structure is not intended or offered for saleSection LOCALITY
7044, Business and Professions Code.) ( MOVING TEL. , 1 ITEMS
® I, as owner of the property, am exclusive) contracting CONTRACTOR NO.
P P Y• Y 9
with licensed contractors to construct the project.(Sec- ADDRESS TOTAL 76 .50
fir.
tion 7044, Business and Professions Code.) [:��{: �t<r°•!I 1
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD FiWY: PROP. LINE WIDTH `: �E
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE M T = ,' C. {y r�yy}� {{y y
P.L: 2Y "I � r,^••. 0000-0101 11/31!V
Lender's Name �y 1 Alp�
-
P.C. Fee$ yLDMA Ref. #► Permit Feet ) E? ti�V l Oe;L
Lender's Address oil
o I certify that I have read this application and state that the � � Issu came LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
8 ordinances and State laws relating to building construction, I.— Tot&Wee LDMA Perm. #
a and herebyaut r ze.representatives of this County to enter
upo abov - entione r,inspection purposes. C4 M C�C1i C'o
a
III-P7 S "JtESE F ,
OX�L�►W470RY L$�r GUAGE
Signature of Applicant or Agent Date 6` �' -o '��