HomeMy Public PortalAbout5752AGNES AVE_Building (2) WORKERS'COMPENSATION DECLARATION
hereby.aft m that I'havecertificate of consent- to Self P P L I CATION FOR BUILDING PERMIT
insure; or a certificate of Workers' Compensation Insurance, ,
oi'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 ADDREss J .
ElCertified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
Date Applicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' - NO:OF BLDGS. - NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit-is for one - ASSESSOR„, ”
hundred dollars ($100)or less.,).. TRACT BLOCK LOT NO. MAF BOOK PAGE PARCEL
1 EL.
OWNER / - NO. " � ,,3�� USE ZONE MAP
I'certify that in the performance of the work for which this _ SPQECIAL'
S
is issued, I shall not employ any person in any manner ADDRESS' /J �� CONDITIONS
so as to become subject to the Wor rs'Compen,s.''6tion Law
1 - y U
//. .� CITY ZIP / .t9
Date`s Applicant ARCHIT CT OR TEL. O
NOTICE TO'APPLICANT: If, after aking this'Ceriificate of DISTRICT' GROUP TYPE FIRE PROCES D BY
ENGINEER NO,. _ CONST. ZONE
Exemption, you-should become subject to the Workers' � `/ �y,) W
Compensation provisions of thelLabor Code, you must forth- ADDRESS .S aP V IL
with comply with such provisions or. this permit shall be TEL. STATISTICAL CLASSIFICATION APT. C NDO:
deemed revoked. CONTRACTOR 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 LIG SEWER MAP
Professions Code, and my�license is in full force and effect. CITY CLASS BK PG -VALIDATION
SQ..FT._ NO. OF NO. OF. CHECK
License Number Lica Class SIZE STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK "; NEW ❑ / (�
Contractor Date _ ADD $
El1 am exempt under Sec. / ALTER
B.&P.C. for this reason .` tX/ . v.- REPAIR .-E] $ - 9 4 8 9.5-A
Date:' IgSE OF
Dt DEMOL Q # o 0 0'0• 0.1 .
EXISTING BLDG. 7?
APPLICANT TEL.
Signature (PRINT) 1,:n T NO_ FINA (, 0 0 4 9,
OWNER-BUILDER DECLARATION DAT
L a
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason+(Section 7031.5, Business and ADDRESS F l o o' 0 49,880
Professions Code)`' PRESENT
BUILDING _ 1 0 6 2 6.`8 6'
1, as owner of theproperty, 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. t
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- '
.tion 7044, Business and Professions Code). REQADDRESS
CONSTRUCTION LENDING AGENCY' SETT BACK YARD HWY TOTAPREOTPAINEFRO - 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.L.
(Sec. 3097, Civ. C.). SIDE. '
Lender's Name j I
o LDMA Ref # \
m _ P.:C. Fee$ _ Permit Fee
Lender's Address
>
t I certify that I have readthisapplication and state-that the - Issuance Fee - J LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to-building construction, .•- ._ _ Total Fee A LDMA-Perm. # "
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
( Signature of Applicant or Agent Date - _ - - •�, •"' OO i
k