HomeMy Public PortalAbout5758AGNES AVE_Building (2) WORKERS' COMPENSATION DECLARATION
nsurebyoraafcertificate ohf Wakcertificate' ensaconsent
onSeInsuranc if APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING r!f
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS o �
❑ Certified copy is filed with the county building inspec- BUILDING r�
tion department. ADDRESL 7� La% ))
Date Applicant CITY LL IP % LOCALITY CSL
Pp NO. Cry
BLDGS. s� NEAREST
CERTIFICATE OF'EXEMPTION.FROM WORKERS' SIZE OF'LOT 6 Q NOW ON LOT .0 CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if The permit is for one TRACT BLOCK I LOT NO., 4 MAP BOOK ��� PAGE TY PARCEL
hundred dollars ($100) or less.) G Q
OWNER W AIV O ZS 5--/ USE ZONE MAP
I certify that in the performance of the work for which this NO. }
�.. SPECIAL t1
permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS O
so as to become subject to the Workers' Compensation Laws. U
CITY ZIP
Date Applicant ARCHITECT OR TEL. DISTRR
GgOUP TYPE FIRE CES D BY
NOTICE TO APPLICANT: If; after making this Certificate of ENGINEER NO. �; (JCONST. ZONE0Exemption, you should becoMe subject to the Workers' I(\L ty
Compensation provisions of the Labor Code, you must forth- ADDRESS a
with comply with such provisions or this permit shall be TEL STATISTICAL CLAsffl ATION APT. CO Z
deemed revoked. CONTRACTOR NO. CL/� —
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
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 Lic. Class SIZE I STORIES FAMILIES ONE
VALUATIO /� �r!��{�
Contractor Date DESCRIPTION OF WORK NEW ❑ $ �/ ► V "
ADD ❑ • Poo.ElI am exempt under Sec.
ALTER ❑
B.BP.C. for this reasonREPAIR E
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL. 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 FINAL
Professions Code): PRESENT By
BLD
❑ 1, as owner of The property, or my employees with ADDRESS ( : Qa
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY , `33 l7 �S.63
7044, Business and Professions Code.) MOVING TEL. M{
❑ I, as owner of The property, am exclusively contracting CONTRACTOR NO. I I E S
with licensed contractors to construct the project Sec- 96 - 63
--e
P I ( ADDRESS ;F��jy)_ 96 - 63
tion 7044, Business and Professions Code.) _
REQUIRED TOTAL SETBACK FROM EXIST. CHECK r"�' i-
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH �••`•�ECK 7''r.63
I hereby affirm that there is a construction lending agency for FRONT CHECK
r r.:
the performance of the work for which this permit is issued P.L.
_ L'l•'i
(Sec. 3097, Civ. C.). SIDE CHARGE
Lender's Name.
LDMA Ref. N
� P.C. Fee$ Permit Fee • CJ...! i ! I '1
Lender's Address 130010—I�0I31i ga1:.i :.C1I�
o 3 i 0 LDMA P/C# , ,. -'C,1 1 i'It t 11:'.24
0
I certify that 1 have read this application and state that the Issuance Fee �;.L
8 above information is correct: I agree to comply with all County Investigation Fee
R ordinances and State laws relating to building construction, Total Fee C1 E LDMA Perm.'#
a and hereby authorize representativ of.this.County toenter
upon the above-Mbntioned proper for inspeQon purpo es.Q
I'7 U SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date