HomeMy Public PortalAbout5812AGNES AVE_Building (3) WORKERS COMPENSATION DECLARATION
iserebo affirm that I have r o
certif10ate of consent to Self APPLICATION FOR BUILDING PERMIT
tsure or a certificate of VO�ukers Cmpensation Insurance
r a certified copy thereof (Sec 3800 lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
olicy No Company ;
Certified copy is hereby furnished BUILDING
FOR APPLICANT TO FILL IN ADDRESS y!04 v
Certified copy is filed with the county building inspec BUILDING ,
tion department ADDRESS J
p` LOCALITY j �r
ate Applicant CITY ZIP (/ O CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERSO OF BLDGS ASSESSOR
I COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
'his section need not be completed if the permit is for one USE ZONE MAP v.2��
undred dollars ($100)or less ) TRACT BLOCK LOT NO / NO I
TEL ` — 1 SPECIAL ' >_
certify that in the performance of the work for which this OWNER (? CONDITIONS d.
ermit is issued I shall not employ any person inp ny manner %r DISTRICT GROUP TYPE FIRE PRO SSED BY O
as t?bome subject;o the W rkers Comperfsation Laws ADDRESS G - / A� CONST ZONE
ate ppli�?hr, r7 CITY e IP STATISTICAOf L/CLA/SpSvIFICATION(J/ 3 APT CONDO O
OTICE TO APPLICANT If after making this Certificate of ARCH EC7 OR i TEL V
(emption you should become subject to the Workers ENGINEER i NO CLASS NO o20 DWELL UNITS W
ompensation provisions of the Labor Code you must forth CL
ADDRESS a SEWER MAP i H
ith comply with such provisions or this permit shall be Z
eemed revoked is TEL E l�� VALIDATION
CONTRACTOR NO BK PG �
LICENSED CONTRACTORS DECLARATION 1 LIC
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION
ommenang with Section 7000)of Division 3 of the Business and LIC
-ofessions Code and my license is in full force and effect CITY CLASS $
SQ FT NO OF - NO OF CHECK
cense Number Lic Class SIZE STORIES FAMILIES ONE
r NEW ❑ $
�niractor Date DESCRIPTION OF WORK
I am exempt under Sec eADD
o ALTER FINAL
B 8P C for this reason REPAIR EJ DATE r -� -
U E OF
Date EXISTING BLDG I DEMOL FINAL
NAL
(Signature �' 'r APPLICANT TEL Y
OWNER BUILDER DECLARATION PRINT 4~M 0 O {
-iereby affirm that I am exempt from the Contractor s License
tw for the following reason (Section 7031 5 Business and ADDRESS .r7 C _ s
ofessions Code) p '
r
J BUILDING V 110/
rt
I as owner of the property or my employees with ADDRESS 7
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section LOCALITY V 1 9 1 b 11A
7044 Business and Professions Code) PADDRE
TEL
] 1 as owner of the property am exclusively contracting CONTRACTOR NO 1 # e o 0 o e 1
with licensed contractors to construct the project (Sec
tion 7044 Business and Professions Code) a Lto o ] 8[�
ED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY K YARD HWY PROP LIN WIDTH opo o ] �j L} v'
hereby affirm that there is a construction lending agency for - ® t ,
e performance of the work for which this permit is issued 0 1 1 8-83
r
,ec 3097 Civ C ) %
tnder s Name
order s Address $ Permit Fee
certify that I have read this application and state that the Issuance Fee>ove information is correct I agree to comply with all County tion Fee
dinances and State laws relating to building construction Total Fee
td hereby authorize representatives of this County to enter
ton the above mentione property for-TTspection purposes
Mi Kerr) r SEE REVERSE FOR EXPLANATORY LANGUAGE
ignoture of Applicant or Agent Date ®s