HomeMy Public PortalAbout5812AGNES AVE_Building (4) F� _ �!
WC2KERS COMPENSATION DECLARATION
affirm that I have a certificate lof consen ur self A P P L I CATION FOR B P I L D I N G PERMIT
'
a certificate of Workers Compensation Insurance
d copy thereof (Sec 3800 Lab C ) - - a
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po` No Company BU LDINGr,
El Certified copy is hereby furnished k1, t FOR APPLICANT TO FILL IN ADDRESS (/
Certified copy is filed with the county building ins'pec BUILDING Q� -
tion department " y r1 ADDRESS ��J 6r, % Ck_ � 1
Date i s Applicant..+ 0 1 a CITY `� ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS - "- -- NO OF BLDGS - NEAREST _
(COMPENSATION INSURANCE
SIZE OF LOT NOW ON LOT CROSS ST
° c
(This se6ion�need not be completed if the permit is for+one TRACT S�y BLOCK b;VOO LOT NO ASSESSOR s f+ ( e
hundred dollars ($100)or, less )+ MAP BOOK PAGE PARCEL
d ` / � TEL
47-6-371
J r/7 6 Y -7/ USE ZONE MAP
I certify that in the performance of the work for which this OWNER' l3 ((� A! NO ff) J NO y
permit is issued I shall not employ any perso in any manner ['� SPECIAL > - d
so as to become subject to the Wor s Co ens n Laws ADDRESS V b 2 -�tl� CONDITIONS y u
v a / 7
1
CITY-- ✓ 1. ZIP !
Date 'gyp Applicant` Q
NOTICE'TO APPLICANT If after mokin this Certificate of ARCHENGINEER OR TEL tT NO DISTRICT GROUP TYPE FIRE PR ESSED BY j C
Exempt I on you should become sub ct to the Workers J� CONST ZONE r
LU
Compensation provisions of the Labor Code you must forth ADDRESS �/t L/� O r Y V
with comply with such provisions or this permit shall be _ _- _ _ r _ _ y,
deemed revoked s t p s TEL , STATISTICAL CLASSIFICATION L APT ONDO
.1 CONTRACTOR NO , _ .,
LICENSED CONTRACTORS DECLARATION,- I - -LIC CLASS NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO
(comffmencing with Section 7000)of Division13 of the Business and _ + r _ LIC _ SEWER MAP
Professions Code and my license is in full force and effect CITY CLASS BK - PG - VALIDATION `
I , _'., 3 , y ,.
SQ FT NO OF NO OF CHECK
License Number 't+Lict Class ' SIZE y _ STORIES FAMILIES ONE r ,
� VALUATION
CJ _1
I n + DESCRIPTION OF WORK W6 NEW ❑ _
$
Vi W ^
ontractor ` Date ADD V
I am exempt under Sec ` ""' "` 01111.ALTER ❑ t 3 0 7 21A ,
c 1 c p 1
B&P C for this reason _ REPAIR -- -
Date -r USE OF # a o o e e
DEMOL
EXISTING BLDG o - 5-925
APPLICANT - - _ TEL - > FINAL
OWNER BUILDER DECLARATION PRINT _ NO » DATE �6'x a 1-~ 1 -0 5 9 2 5 c=i
I hereby affirm that I am exempt from the Contractor s License k
Law for the following"rreason (Section 7031 5 Business and ADDRESS FIN 4- 1 004 -85
Professions Code) ° - } -- - PRESENT -_ r _ _ By
rV BUILDING
I as owner of the property or my employees with ADDRESS _ l
wages as their sole compensation will do tlib work and _ _
the structure is not intended or offered for sale(Section LOCALITY z '
7044 Business and Professions Code) ---- -- MOVING- - - TEL - - - - -
I as owner of the property am exclusively contracting CONTRACTOR NO -4 °
with licensed contractors to construct the project (Sec -- ADDRESS _ {
tion 7044 Business and Professions Code) "
REQUIRED_ TOTAL SETBACK
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY` 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 ) r s SIDE
P L
Lender s Name
�1 c LDMA Ref #
PC Fee$ - Permit Fee
Lender s Address
I certify that I have read this application and state that the Issuance Fee (/ r kLD P/C#
a above information is correct I agree to comply with all County Investigation Fee r z �+ t
S ordinances and State jaws relating to building construction _ +*
d and heAby authorize representatives of this County to enter Total Fee- - IDMA Perm-# y-
u above enttoned pi rty for inspection purposes - ,+ Y _rt - Y µ
a _.
o � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signator f phcant or Agent - - - Date - _ _ _ _ f LL _ OO