HomeMy Public PortalAbout5745AGNES AVE_Building (4) WORKERS' COMPENSATION DECLARATION {�
hereby affirm that I haver certificate of consent to self APPLICATION F O U I L D I N G PERM
ILIA
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab ) t
i0C� j n -'? L/ y� ��� COUNTY OF LOS ANGELES BUILDING AND SAFETY a
BUILDING
�cy o. ompany
Certified copy is hereby furnished. j {>t r' ?�c� FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed w*thecbuilding inspec- BUILDING tion department. ADDRESS � a 1 LOCALITYNEARET' IF
,n,rY Dote Applica CITY �/�j L C ZIP CROSSSST. W�Ip_l'�CERTIFICATE OF EXEMPRKERS' f / NO. OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT 4OX �� NOW ON LOT /��� MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one �r _ PG1", a SEp,ZONE MAP
hundred dollars ($100)or.less.) TRACT / BLOCK LOT NO. .. y,l
TEL. SPECIAL
�Lr,`/` y Cv{/
I certify that in the performance of the work for which this OWNER tZf1"� NO. CONDITIONS'
permit is issued, I shall not employ any person in any manner /- �_ DISTRICT GROUP fIDE FIRE PROCESSED BY 0
so as to become subject to the Workers'Compensation Laws. ADDREyS^^Sf .i ,� . , -- .. 2 NST. ZONE /�
CITY/ G r ZIP / E/
Date Applicant STATISTICAL CLASSIFICATION APT. CONDO.
NOTICE TO APPLICANT: If, after makingthis Certificate of ARCHITECT OR TEL rV
ENGINEER O. CLA55 NO. �t DWELL. UNITS
Exemption, you should become subject to the Workers' �. .
Compensation provisions of the Labor.Code, you must forth-
with comply with such provisions or this permit shall be ADD TEL SEWER MAP
deemed revoked. CONTRACTOR d NO. BK. I""'PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.�}
I hereby affirm that I am.licensed'Dnderpro'visions of Chapter 9 ADDRESS _/ NO:L� ✓� yALU=4TION
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in $,full force and effect. CITY y CLASS G� G/G'
J SQ. FT. e NO.OF NO. OF f CHECK' ►
License Number 0!2�1�71 Lic.Class !6'7 SIZE Y STORIES FAMILIES / ONE
ContractDate V 7 DESCRIPTION OF WORK / ,45P� 6) NEW
❑
ADD
I am exempt under Sec.
• - ALTER ,❑ FINAL
B.BP.C. for this reasonG_ ❑ DATE
" REPAIR
Date: USE OF FINAL
EXISTING
EXISTING BLDG. DEMOL ❑
t/",-Signature / APPLICANT TEL. Y �i 111
OW BUILDER DECLARATION PRINT � NO..
I hereby affirm that am exempt from the Contractor's License ' C
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): PRESENT
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code).. MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
- o o
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIREDTOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING,AGENCY "'-SET BACK YARD HWY PROP. LINE WIDTH ►
I hereby affirm,that there is a construction lending agency for FRONT v ' �'•�
the performance of the workfor which this permit is issued P.L. ` Ci
(Sec. 3097, Civ. C.). SIDE
m
P.L.
e Lender's Name
Lender's Address
P.C. Fee$ Permit Fee
I certify that I have read this application and state that the Issuance Fee Qf >�
above information is correct. I agree to comply with.all County Investigation Fee a
$ ordinances and State laws relating to building construction, Total Fee .11Zu and h reby authorize representatives of.this County to enter
m up he ab mentioned property for.inspection Pur oses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Applicant or Agent Date es