HomeMy Public PortalAbout5733AGNES AVE_Building (4) WORKERS COMPENSATION DECLARATION ` �l��
f insure�oraa certif carte of Workei;s Compensation Insuran elf APPLICATION F O R U I L D I N ) PERMIT
or a certified copy thereof (Sec 3800 Lab C ) 1 COUNTY OF LOS ANGELES ' BUILDING AND SAFETY "
Pplcy„No Company
> BUILDING
1:1 Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS
El Certified copy is filed with the county building inspec
BUILDING r 4
tion department ADDRESS
S Y
CIN 2ili�c C /7 ~ ZIP ' Sd LOCALITY
Date Applicant NO OF BLDGS NEAREST -
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT ,. ���X I`(0 NOW ON LOT I CROSS ST
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is'for one TRACT. BLOCK LOT NO MAP BOOK PAGE PARCEL t
hundred dollars ($100) or less ) r7 \ TEL _
OWNER' 1 O J v4 r! St+ NO yJ�j USE ZONE MAP
I certify thatlin the performance of the work for which this NO - }
SPECIAL
permit is issued I shall not employ any person in any manner ADDRESS �0 07 C aS
CONDITIONS n O
so as to become subject to the Workers CompensatomLaws y _ - - - U
* CITY P Y� L� s q- ZIPl 7�U
Date Applicant ARCHITECT OR TEL DISTRICT OU TYPE FIRE OCESSED P#eBY 0
NOTICE TO PPLICANT If after making this Certificate4 of ENGINEER NO �j �j� CONST E
Exemption you should become subject to the Workers T}/( K t1{/ LU
a Compensation provisions of.the Labor Code you must forth ADDRESS N
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO Z
deemed revoked CONTRACTOR NO ) —
LICENSED CONTRACTORS DECLARATION LIC CLASS NO ��--3 DWELL UNITS—,L
ADDRESS NO mmmmiiilil
I hereby affirm that I am licensed under provisions of Chapter 9 LIC SEWJ=R MAP
(commencing with Section 7000)of Division 3 of the Business CITY CLASS VALIDATION
*and Professions Code and my license is in full force and effect BK PG Z�
N SQ FT NO`OF NO OF CHECK i�=/Xau
�j
License Number Lic Class SIZE STORIES FAMILIES ONE ' ^
- VALUATION
'Contractor Date DESCRIPTION OF WORK NEW El
❑I am exempt under Sec ° u tYC l �t g_ u�5� ADD -E] s
�+ ALTER ❑ _ q
B&P C for this reason + t ` -` REPAIR ❑ $ _ ' Ste • �-� /►f ,/
Date USE OF
EXISTING BLDG DEMOL
Signature APPLICANT .. TEL - FINAL
OWNER BUILDER DECLARATION (PRINT) NOc DATE 11/43/�
I hereby affirm that I am exempt from the Contractor s License
"Law for The following reason (Section 7031 5 Business and ADDRESS - jF
Professions Code), PRESENT
BUILDING
❑ I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and
LOCALITY
the structure is not intended or offered for sale(Section
7044 Business and Professions Code ) I MOVING - -TEL ,
❑ I as owner of the property am exclusively contracting CONTRACTOR NO ^> �� _ t a` f '
with licensed contractors to construct the project (Sec 4,---
tion
ADDRESS
hon 7044 Business and Professions Code ) fr t I K(T a
REQUIRED TOTAL SETBACK FROM EXIST} °a
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH _ � r .. - _',_, �t
I hereby affirm that there is a construction lending agency for FRONT t f t t 3M `TJ• k
the performance of the work for which this permit is issued PL" I r t '
(Sec 3097 Civ C ) SIDE f(, 1 ITEMS
P L - < r 'TOTAL 60 .50
Lender s Name LDMA Ref #r ° t; 'ri J
PC Fee$ Permit Fee L f, to.JIJ
Lender s Address _
I certify that I have read this application and state that the M b Issuance Fee U rJ'-D LDMA P/C# CHANGE . Ill
8 above information is correct I agree to comply with all County Investigation Fee
ordinances State laws relating to building construction Total Fee G' J� LDMA Perm #
R and rebyLautorzerepresentatives of This County to enter 130010_i0001 10/r`/t9
up e ave m roperty for inspection purposes - t q y�
��L��ET �G�-ZS SEE REVERSE FOR EXPLANATORY LANGUAGE ._ I ++I r 1 1 At! 5-'.,t2
Signature of Applicant or Agent Date '
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