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HomeMy Public PortalAbout5749AGNES AVE_Building WORKERS' COMPENSATION DECLARATION 1,I hereby affirm that I have a certificate.of consent to self vnsure,•ar a certificate of Workers' Compensation Insurance, APPLICATION FOR . BUILDING . PERMIT ot,a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Polic No. ® CompanyBUILDING --S/'"��l"�_J� ✓ Ce"rtified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS / > g � { CITY ( ZIP f 7 LOCALITY , Dated "� l© Applicant1 1 , NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FRO WORKERS' SIZE OF LOT NOW'ON LOT 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. hundred dollars ($100) or:less.) TEL. OWNER NO „S t� USE ZONE MAP 9 / !/ I'certify that in the performance of the work for which*this NO. permit is issued, I shall not employ any person in any manner ADDRESS rAr�,;• / SPECIAL CONDITIONS so as to become subject To the Workers' Compensation Laws. O CITY 'r ZIP / U U Date Applicant ARCHITECT OR TEL. 0 NOTICE TO APPLICANT: If, after_•makin this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY 9 CONST. ZONE � Exemption, you should become.,subject to: the Workers' w Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or- this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. to deemed revoked. CONTRACTORS NO 7 (a _� / Z LICENSED_ CONTRACTORS DECLARATION LIC. CLASS NO. (>e— UNITS I hereby affirm that I am licensed under provisions of.Chapter 9 ADDRESS G / NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER.MAP and Professions Code,and my license is in full force and effect. CITY WC a CLASS G'j 9 BK PG VALIDATION SQ:FT. Q� NO. OF NO. OF CHECK License Number .7i!75 Lic. Class SIZE � E7 STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK NEW ❑ Contractor @Prlfrfi►rf i�T1�1'T ' Date l "-� � � '$ 'Irl 6110 0 -, ADD ❑ ❑I am exempt under Sec. ) pop.1, � ALTER ❑ B.&P.C. for this reason Cr �-4S.< REPAIR $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. t� FINAL_ OWN - LDER DECLARATION (PRINT) NO. !�'11 � 0 DATE r t �_13 . I hereby affirm that I exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS �Q 6 L� G/ FINAL-_- Professions Code): PRESENT By BUILDING `"' °1 ❑ I, as owner of the property, or my employees with ADDRESS. 07 wages as their sole compensation,will do the work and J � the structure is not intended or offered for sale(Section LOCALITY y/ /f 7044, Business and Professions Code.) MOVING TEL. " iTE r)S ❑ I, as owner of the property, am'exclusive) contracting CONTRACTOR NO. YI-{ • ate+"a 3 P P Y� Y 9 1�€1... T•�.} m with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) '•:`ems;- .REQUIRED TOTAL TOTAL SETBACK FROM JE CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE 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 0-01 1 Lender's Name Lender's AddressP.C. Fee.$ Permit Fee A Ref. # v < y ;y1 certify that 1 have read this application and state that the Issuance Fee A P/C# 0above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee � [ A Perm. # c and hereby authoriz epresentatives of this County to enter upon a above-m ti ned property for inspection,purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signa a of Applicant or Agent Date