HomeMy Public PortalAbout5733AGNES AVE_Building (3) Y
WORKERS COMPENSATION DECLARATIOI`�6 1 f ..
hereby affirm that I have a certificate s can ent to self p p�I CATION FOR UEDINGDING PERMIT
insure or a certificate of Workers Compens )once or
i cert fpie� py thereof 3800 Lab C
N' r,PJ`��f� man b COUNTY OF LOS ANGELES�� AND SAFETY
P Y y
1 Certified copy is hereby furnished/_ �i� FOR APPLICANT TO FILL IN BURESS
ILDING
ADD �I
�Cerhfied copy is filed with the county but ding inspec BUILDING )-
tion department t ADDRESS G LOCALITY
Date Applicant CITY �1' NEAREST
pp C l� ZIP ► CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS QNO 1OF S /
tf— ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT S'`1 Y� NOW ON LOTMAPBOOK PAGE PARCEL
(This section need not be completed if the permit is for oneU 0 MAP
TRACT BLOCK- LOT NO B
G
hundred dollars ($100)or less ) � t NO }
�O J D TEL SPECIAL d
I certify that in the performance of the work for which this OWNER 1 NO CONDITIONS 0
permit is issued I shall not employ any person in any manner STRICT GROUP TYPE FIRE PROCESVb BY U
so as to become subject to the Workers Compensation Laws ADDRESS N CONST Z
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J , ` v C!/
CITY ZIP
Date Applicant STATISTICAL CLAS CATION PT CONDO (J
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL W
Exemption you)should become subject to the Workers ENGINEER NO
CLASS NO DWELL UNITS N
Compensation provisions of the Labor Code you must forth - ADDRESS SEWER MAP Z
with comply with such provisions or this permit shall be
deemed revoked TEL
CONTRACTOR O BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION f�jj
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 227 —3 VA TION /
(commencing with Section 7000)of Division 3 of the Business and LIC {�
Professions Code and my license is n full force andeffectt CITY / CLASS W $ e/
2—z4 3 yrt;�� SQ FT NO OF NO OF CHECK
License Numk44)"
beerrv`/' `7 Ltc Class �,) �� SIZE sSTORIES FAMILIES ONEf� �IL Date 1 a-1 "a NEW $
Contractor_ r DESCRIPTION OF WORK
I am exempt from the licensing requirements as I am a �� 0 (�. ADD - r
licensed architect or a registered professional engineer ALTER FINAL
acting in my professional capacity (Section 7051 ` REPAIR DATE
Business and Professions Code) USE OF ❑ /
EXISTING BLDG DEMOL By FINAL
Lic or -tReg No Date APPLICANT TEL ��yy� (/
OWNER BUILDER DECLARATION (PRINT) NO"I�D�
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and ADDRESS / ^
Professions Code) \ PRESENT
BUILDING _
I as owner of the property or my employees with e ADDRESS l 2 2�2 A
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 e #t° •fO`O •
I as owner of the property am exclusively contracting CONTRACTOR t NO 2 -,- 5200
with licensed contractors to construct the project (Sec ADDRESS-
r tion 7044 Business and Professions Code)
REQUIRED TOTAL SETBACK FROM EXIST f ° - 52005:
I hereby affirm that there is a construction lending agency for FRONT ^ 12 1 1 -81„^$ 1
the performance of the work for which this permit is issued P L j�
(Sec 3097 Civ C ) SIDE '
PL
Lender s_Name `
Lender s Address P C Fee$ Permit Fee �r 6V
r
w certify that I have read this application and state that the Issuance Fee
aabove information is correct I agree to comply with all County Investigation Fee �J
ordinances and State laws relating to building construction
ereby authorize representatives of this County to enter Total r
aup the e mentioned property for inspect n purposes
a SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant gent ate Os