HomeMy Public PortalAbout5758AGNES AVE_Building WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insUrr�-, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
P i Y N1&gA—Company �T�F1r�?/A,�Q
Certified co is hereby furnished. 7,:5
APPLICANT TO FILL IN BUILDING
copy y ADDRESS
Certified copy is filed with the county building inspec- fADDRESS
tion department. % L �/ ZIP LOCALITY
Date r Applicant ' ` NO. OF BLDGS.
C RTIFICATE OF EXEMPTION FROM W KERS'. SIZE OF LOT M NOW ON LOT NEAREST
CROSS STVt
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.) pY�NER TEL._�9 0!
NOp(tS< Y YAC USE ZONE MAP
NO.
I certify that in the performance of the work for which this `f�y SPECIAL >_permit is issued, I shall not employ any person in any manner' ADDRESS � <i CF 0'J CONDITIONS a
so as to become subject to the Workers'Compensation Laws. s OU
CITY .F �—, ZIP'
Date Applicant ARCHITECT OR T A TEL. 0
ENGINEER �. G' DISTRICT' GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of a NO. CONST. ZONE V
Exem tion, you should become subject to the Workers' '�J /� �iLU
Compensatin provisions of the Labor Code, you must forth- ADDRESS S j, 0 ,� N
with'comply with such provisions or this permit shall beTEL.� TATISTICALCLASSIFICATI APT. CONDO. Z
deemed revoked. CONTRA B ' 45
LICENSED CONTRACTORS DECLARATION t�i� LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. l �� �
(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 . ��/�/, ��. CLASS BK PG VALIDATION
��}} / SQ. FT. NO.-OF / NO. OF CHECK '
License Number( 601 ��o/_l Lic.. Class Q SIZE STORIES / FAMILIES ONE VALUATIO L�-•-
Coniroc�9fSl'v`�l/1 //CG+ /% DESCRIPTION OF WORK////� /�� T NEW a ' '" `
"'o cv o� ADD C7( L/C✓ ► _ is
❑I am exempt under Sec. _
� ALTER ❑ -
B.&P.C. for this reason // REPAIR ❑ $ �µ
USE OF i i "f`•,:
Date: EXISTING BLDG.V%�Jv4�_ /G AE1 DEMOL ❑ X. -2_ {
Signature APPLICANT TEL. FINAL 9 ';"){ E _i _ a Ci
'OYKER-BUILDER DECLAR T O (PRINT) NO. DATE �� 1 1 'u
I hereby affirm that I am exempt from the Contractor's License + »cz
Law.for the following reason (Section 7031.5, Business and ADDRESS FINAL (sf�
'HA
Professions Code): PRESENT By
❑ I, as owner of the property, or my employees with BUILDING
ADDRESS
wages as their sole compensation,will do the work and / "
the structure is not intended or offered for sale(Section LOCALITYI=I'I=`= `JI`(=s "f
TEL.
MOVING
7044, Business and Professions Code.)
CONTRACTOR NO. _,�r�� � _ 3 y H;'
❑ I, as owner of.ihe property, am exclusively contracting
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with licensed contractors to construct the project (Sec-
ADDRESS
tion 7044, Business and Professions Code.),
REQUIRED TOTAL SETBACK FROM EXIST.
YARD HWY
CONSTRUCTION LENDING AGENCY SET BACK 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.
Lender's Name.
LDMA Ref. #
P.C..Fee
Lender's Address $ or 60 Permit Fee ,
�
o I certify that I have read this application and state that the Issuance Fee / 3. LDMA P/C#
a
8 above information is correct. I agree to'comply with all County Investigation Fee Q
d ordinances and State laws relating to building construction, Total Fee 190% 9�9� LDMA Perm. #
a and here, iize representati s this Count 'to enter
upon Thea e-m n necl rt
y inspecti purp s.
t /w SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Applicant ent Date