HomeMy Public PortalAbout5739AGNES AVE_Building (2) ; WORKERS'COMPENSATION DECLARATION
nsurebor afirm certif catte off Workers' Compensatioa certificate' of n Insuranceent to , APPLICATION FOR BUILDING PERMIT ' �
or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING n 2
ADDRESS ` �•J
Certified copy is filed with the county building inspec- BUILDING' r
tion department. ADDRESS
Date Applicant CITY f4,44 l T ZIP �' LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS.. NEAREST .
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. 1.416
This section need not be completed if the permit is for one .L(_ ASSESSOR ,
hundred-dollars ($100)or less.) p TRACT BLOCK LOT G' p MAP BOOK PAGE PARCEL
TEL U"CONDITIONS
AP
OWNER , NO. ���
I certify that in the performance of the work for which this O.-
permit.is.issued, I shall not employ any person in any manner ADDRESS ECIAL
so as to become subject to the Workers'Compensation Laws. U
t r CITY ZIP OC
Date pplicant �" ARCHITECT OR // ,/} TEL _
NOTICE TO AP ICANT''Jf, after mak' this Certificate of ENGINEER ) L, !" DISTRICT _ GROUP. TYPE FIRE PROCE SED BY
Exemption, •you .should become subject to the Workers' NO. LL �( �j CONST1� ZONE
us
-
Exemption,
provisions of the Labor Code, you must forth- ADDRESS Jt� (!L �`-� ✓ -�-
with comply with such provisions or this permit shall, be - TEL. STATISTICAL CLASSIFICATION APT. C DO.
deemed revoked. CONTRACTOR /V� �{/� NO.
LICENSED CONTRACTORS DECLARATION• LIC. - CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Profession_s Code, and my license is in full force and effect. CITY CLASS BK VALIDATION
SQ. FT: NO. OF NO. OF CHECK
License Number Lic.Class SIZE r STORIES J- FAMILIES r ONE
❑ VALUATION _
Contractor Date DESCRIPTION OF WORK' NEW E r��1r
"4(f 4(f! J / ,
I am exempt under Sec. !Z-- �� a ADD_
ALTER
B.BP.C. for This reason _ -7-1 �? v 97 ❑%Q `� ,,���� b'' REPAIR $
USE OF
r✓ - -
Date: EXISTING BLDG. k46 J 6,4/C �~ DEMOL ❑
Signature APPLICANT % TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT) NO. DATE -
749
hereby affirm that I:am•exempt from the Contractor's License #
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT By ZA l o o 3300
BUILDING �L & ti o o 1 3 Q Q v
_ I, as owner of The property, or my employees with _ ADDRESS ELM
s� wages as their sole compensation,will do The work and 'T�+ n �-+
the structure is not intended or offered for sale(Section LOCALITY L�'> Y' �6 C 7Y F� , 0 53 1 i 8 5 t
7044, Business and Professions Code). r MOVINGAID
, TEL.
El1, as owner of the property, am exclusively contracting CONTRACTOR /V D,/ NO.
with licensed contractors To construct-the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY REQUIRED TOTAPREOTPAINEFROM - WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the'performance-of the work for which this permit-is issued P.Lr
(Sec. 3097, Civ. C.). SIDE
P.L. •
Lender's Name
o LDMA Ref. #
Lender's Address
P.C. Fee$ Permit Fee
- _ -
_-I certify that I have read this application,and state that the Issuance Fee t/a `S LDMA P/C#
a above information is correct. I agree to comply with all County Investigation Fee '
ordinances and State laws relating to building construction, J _ •. _ .
t; and hereby authorize representatives of this County to enter Total Fee LDMA Perm: #
pon the above-m i ned property7for inspection purposes.
a
o 2 j- S SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of AP cant or Agent - Date -- - -- - - -