HomeMy Public PortalAbout5806AGNES AVE_Building (3) •0V0 F_-_RE1'COMPENSATION DECLARATION-
su re,or dl r��that I have r certifompens unser;,.ren e, • APPLICATION FOcl
R BUILDING PERMIT c
insure, or a•Certificate of Workers' Compensation Insuri:nce,
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS U ,6
❑ Certified copy is•filed with the county building inspec- BUILDING
tion department" ADDRESS blp4jes A06
Date Applicant- CITYZIP
q 17 a LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' i NO. OF BLDGS. NEAREST j,
COMPENSATION INSURANCE SIZE OF LOT < l NOW ON LOT CROSS ST. W
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less,) TRACT BLOCK �s LOT NO.p/ ® y MAP BOOK PAGE PARCEL
N I` NO 6._
f USE ZONE MAP
OWNER. (J �
I certify that in the performance of the work for which this ,.�/� ///►►► NO.
permit is issued, I shall not employ any person in any manner ADDRESS U . �G � SPECIAL d
so Oslo become subject to'the Work 's'Comr sation Laws. GG /� P CONDITIONS u
��^Q LA CITY .. 7V 0 ,� (.� ZIP �.$d
Date �� L 'Applicant'' ARCHITECT OR TEL. O
NOTICE TO APPLICANT: If, after making t is tificate of DISTRICT GROUP TYPE FIRE PPR/�//O'//{��jgqESyySED BY. F.
ENGINEER NO. 05CONST. ZONE \Awv� UA
Exemption, you' should become subjec o the Workers' ^ ,/
UA
Compensation provisions of.the Labor Code, you must forth- ADDRESS V 1 O V 3 CL
with 'comply with such provisions or,,this•permit shall beN
TEL. ^ ` C STATISTICAL CLAS IFI'ATION APT. CON Z
deemed revoked.• CONTRACTOR NO226
�j �t3c7
LICENSED CONTRACTORS DECLARATION P '"L6 S LIC J Z CLASS NO. DWELL..UNITS
I hereby affirm that l am licensed under provisions of Chapter 9 ADDRESS
p�
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP
-
Professions Code, and my license is in full force and effect.
-CITY S CLASS ^' VALIDATION
(f 3q,
��fQ SQ. FT. NO. OF NO. OF CHECK
BK. �� .
License Number l `,� �" / O� Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor h Date lDESCRIPTION OF WORK A D E] S � V �
❑ I am exempt under Sec. O�{1� EJ ,
• � _ ALTER
B.&P.C: for this reason REPAIR ❑ $
Date: USE OFDEMOL ❑
EXISTING BLDG. OU S^Z
Signature ` APPLICANT TEL. �L/ FINAL
OWNER-BUILDER DECLARATION PRINT) AcA NO. ` DATEg - ✓
I hereby affirm,that I am exempt from the Contractor's License �/ C �J 5 p ;�0'8.4,ZA
Law for the following reason(Section 7031.5, Business and ADDRESS `Z G•.Y �� (�Z�. FINAL 0 0 0 0 0
Professions Code): PRESENT BY / ) � / � # 1
BUILDING
❑ I, as owner, of the property, or my employees with ADDRESS - 28200.
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.
❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct-the project (Sec- ADDRESS
tion 7044, Business and Professions Code). ° ° 2 8 2 O 07-
REQUIRED
TOTAL SETBACK FROM IST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT Q O 9-=8 4
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
Lender's Name _
m LDMA Ref. #
- -• - - P.C. Fee$ Permit'Fee - Ll l:s - - - - - -
- Lender's Address _
I_-certify that I have read this application and state that the .. Issuance Fee S LDMA P/C# }
a above information is correct. I agree to comply with'all County Investigation Fee
ordinances and State laws relating to building construction, Total-Fee LDMA Perm. #
U and hereby authorize representatives of this County to enter
m upon the bove-menti A d property for inspection purposes.
_5_ SEE REVERSE FOR EXPLANATORY LANGUAGE
'Signature pplic or Agent Date �°