HomeMy Public PortalAbout5806AGNES AVE_Building (2) WORKERS' COMPENSATION DECLARATION
ns1,eboraffirm
acertifitatteofWokes' Compe�sa;on5I�su�a�ce, APPLICATION FOR BUILDING PERMIT
,or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑
BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS G✓�p
❑ Certified copy is filed with the county building inspec- BUILDING f
tion department. ADDRESS Q IG
Py
CITY �I ZIP q I 7eO LOCALITY l�GCG
Date Applicant NO. OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT NEAREST
CROSS ST.
COMPENSATION INSURANCE ASSESSOR 'f
(This section need not be completed if the permit is for one BLOCK LOT NO. MAP BOOK �/ PAGE PARCELv/�
�
hundred dollars ($100) or less.) �r p ( i TEL.,
OWNER ri t4'C L rJ `OU'.C� NO t USE ZONE MAP
I certify-that in the performance of the work for which this / SPECIAL o SPECIAL �
permit is issued, I shall employ any person in any manner ADDRESS _ lJ L CONDITIONS
so as to become subject to the Workers' Compensation Laws. t ` OU
CITY"rfO� l� `� ZIP U
Date Applicant ARCHITECT OR TEL. ^ DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. • ,AIN CONST. Z NE (—
Exemption, you,should become subject to the Workers' U
,/
Compensation provisions of the Labor Code, you must forth- ADDRESS J d x4j r � � wN
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO.
deemed revoked. CONTRACTOR NO. /r J Z
LICENSED CONTRACTORSDECLARATION LIC. CLASS NO._��/T//_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. FTNO. OF NO: OF CHECK
S
License Number Lic. Class SIZE STORIES FAMILIES ONE '
❑ VALUATION.
Contractor Date DESCRIPTION OF WORK NEW $ 4010
El am exempt under Sec. e e � j��, ADD Poo.01111111❑
B.&P.C. for this reason REPAIR ❑ a
Date: USE OF
EXISTING BLDG. DEMOL ❑
APPLICANT _ TEL.
Signature (PRINT). NOFINAL
.
OWNER-BUILDER DECLARATION DA
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINW�A
;
Pr fessions Code): PRESENT BY ,t
j I, as owner of the property,.or m employees with BUILDING ti `• ( air
y� P P Y YADDRESS
wages as their sole compensation,will do the work and i
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL.
CONTRACTOR NO. _
❑ I, as owner of theproperty, am exclusive) contracting ''—•
Y 9 i i�l t iL ��._ � •.�i'�
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code. CA'
�`)
REQUIRED TOTAL SETBACK FROM '• EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH A,^,
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for hich this permit.is issued P.L.
(Sec. 3097, Civ. C.). ; SIDE _ _ �r
P.L. •F '—D1 l:
Lender's Name I3:! I`t,,�
a f{ LDMA Ref. #
P.C. Fee$ Permit Fee
� Lender's Address ,
0 1 certify that I have read this application and state that the Issuance Fee ' LDMA P/C#
$ above information is correct. I agree to comply with all County Investigation Fee
R ordinances and State laws relating to building construction, Total Fee p LDMA Perm. #
a and hereby authorize representatives.of this County to enter
2 upon t above-mentioned proper y for inspection purposes.
GSEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of plicant of Agent Date i