HomeMy Public PortalAbout5752AGNES AVE_Building (4) WORKERS'COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING P E RM I T
insure, or a certificate of Workers'Compenstion Insurance, or
a certified copy thereof (Sec. 3800, lab. C.) I
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.ylo7lp 74/ Company5rat' .C�em02 '
❑ -Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS -T-2—
Certified copy is filed with the county building inspec- BUILDING
tion department: ADDRESS SJ ( �s LOCALITY
�► Z 8Z NEAREST
Date Applicant CITY ZIP ?(p CROSS ST. (�(/
CERTIFICATE OF EXEMPT FROM WORKERS' NO. OF BLDGS. ASSESSOR
COMPENSATI INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be co pleted if the permit is for one USE ZONE EMAPTRACT BLOCK LOT NO.hundred dollars ($100) or less.) TELI certify that in the performance of the work for which this OWNER - �• O, - ONS
U
permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PRO SED BX
so as to become subject to the Workers'Compensation Laws. ADDRESS` eS v Ti� CONST. ZONE ag
-4 Date Applicant CITY ZIP 7 0 STATISTICAL CLASSIFICATION _J APT. CONDO.
2 U
NOTICE TO APPLICANT: If/ lifter making this Certificate of ARCHITECT OR TEL. I W
Exemption, you should become subject to the WorkersENGINEER NO. CLASS NO. DWELL. UNITS K
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be ADDRESS SEWER MAP'
.
deemed revoked. E � VALIDATION
S OK TELNOoZES 57.60 BK. CPG,LICECONTRACTOR NSED CONTRACTORS DECLARATION UC. p q
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1007 .- ltre NO..3O 2-Q O Z- VALUATION
(commencing with Section 7000)of Division 3 of the Business and � ,�,, �,pp LIC o-�
Professions Code, and my license is in full force and effect. CITY%"' CQc-Allo-Q- CLASS C -3 q $ ISO O
`, SQ. FT. NO. OF NO. OF CHECK
License Number`' �� Lic.Class SIZE STORIES FAMILIES ONE
Contracta DESCRIPTION OF WORK Pe- {`O Q NEW ❑ $
Contractor to ��-!2.-b'Z ❑
I exempt from the lice sing requirements as I am a ADD
li nsed architect or a r istered professional engineer ALTER ❑ FINAL
acting in my professional capacity (Section 7051, REPAIR DATE
Business and Professions Code). USE OF ❑ �
EXISTING BLDG. DEMOL By AL
Lic.or Reg. No. _Date APPLICANT TEL.
OWNER-BUILDER DECLARATION (PRINT) NO.
I hereby affirm that I am exempt from the Contractor's License -
Low for the following reason (Section 7031.5, Business and ADDRESS
,Professions Code): PRESENT
❑ BUILDING 6 7 8. 3 A
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and i�
the structure is not intended or offered for sale(Section LOCALITY 0 0 0 0 0
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. 2.a o U.3,0 0
with licensed contractors to construct the project (Sec- rFRONT
S o 0 0 () 3,d `.
tion 7044, Business and Professions Code). -
RED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY ACK YARD HWY PROP. LINE WIDTH 10A 1 2-82
1 hereby affirm that there,is a,construction lending agency for
the performance of the work for which this permit is issued(Sec. 3097, Civ. C.).
Lender's Name r
Lender's Address P.C. Fee$ Permit Fee J v
w I certify that I have read this application and state that the Issuance Fee
aabove information is correct. I agree to comply with all.County Investigation Fee v Od
0 ordinances and State laws relating to building construction, Total Fee
w e and hereby authorize representatives of this County to enter
aupon the above- enti6ned property f r inspection purposes.
a 1,,1--I2—g 2. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App icant oe nt Dote �s