HomeMy Public PortalAbout5757AGNES AVE_Building � WORKERS' COMPENSATION DECLARATION `— r L N 3d
insure, raafcertif carte of Workers' Comtpensat on eInsuran elnt to f APPLICATION P FOR R U I L D I N RMI T
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDIN
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS"
Certified copy is filed with the county building inspec- BUILDING S ie S NeS V�'
tion deportment. ADDRESS V�Q
Date Applicant CITYT42� (e ZIP �•+ 0 LOCALITY <--
CERTIFICATE
- {C..-
CERTIFICATE OF EXEMPTION FROM WORKERS' py NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS S7.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL USE Z NE MAP
I certify that in the performance of the work for which this OWNER r'QeS O. NO.
permit is issued, I shall not employ any person in any manner 5-757 hes- e I SPECIAL
so as to become subject to the Wor rs' Compensation ws. ADDRESS /// ��\ CONDITIONS
-^ CITY e / ZIP / 7
Date Applicant ARCHITECT OR ,p TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER ` NO DISTRICT GROUP TYZONE
PE FIRE PROCESSED BY
Exemption, you should become subject to the Workers' CONST. �NE
Compensation provisions of the Labor Code, you must forth- ADDRESS ✓`t/ U�`� ✓
with comply with such. provisions or this permit shall be ( TEL. [ STATISTICAL CLASSIFICATION APT. CO DO.
deemed revoked. CONTRACTOR e � J NO. 9 J
LICENSED CONTRACTORS DECLARATION f.� LIC. O g,g CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 7394r n 0 D p� NO.
(commencing with Section 7000)of Division 3 of the Business and - l n LIC. SEWER MAP
Professions Code, and my license is in full force and effect. CITY o/ ✓�'� CLASS BK PG VALIDATION y;
SQ. FT. NO. OF NO. OF CHECK O.
License Num �Lic.C.
s SIZE ' OQ STORIES FAMILIES ONE O
` VALUATION C)
DESCRIPTION OF WORK QWiU �t1 @ (aC EW ❑ 04
Controctor ate �j
J�/ F Q �a YK CAt ADD ❑ S V , O
El I am exempt and r Sec. ❑
�v ��- AJXERLU
B.&P.C. for this re on e4 7e C S' eC.7 REPAIR $
USE OF
Date: EXISTING BLDG. 2f l& DEMOL ❑ z
Signature
APPLICANT EL. FINAL _
OWNER-BUILDER DECLARATION (PRINT) NO. DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS �� Bn �� FINAL/
Professions Code): PRE ENT By
BUILDING 'V
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 y NO.
with licensed contractors to construct the project (Sec- [ADDsR'SS
tion 7044, Business and Professions Code).
REQUIRED- TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY ET BACK, YARD HWY. PROP. LINE 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
P.L. r• _, ; w C.-.i 4.. ,
Lender's Name
LD
. Fee$ Permit Fee ;e;; ;r7 _
Lender's Address ��)) +, i '�
oI certify that I have read this*application and state that the Issuance Fee 0 �U LDMA P/C
above information is correct. I agree to comply with all County eti otion Fee // C
0 ordinances and State laws relating to building construction, 9 Total Fee b� LDMA Perm. q
and hereby authorize•representatives of this County to enter
up above-mentionederty for inspection purposes. :r
`p (�` SEE REVERSE FOR EXPLANATORY LANGUAGE on
Signature of Applicant or Ag t Date .,;ry .,,�� ,"i i j J`t _