HomeMy Public PortalAbout5812AGNES AVE_Building (5) WORKERS COMPENSATION DECLARATION {
APPLICABON FOR BUILDING PERMIT
I hereby affirm than1 have,a certificate of .fln Ott self ' t
insure or a certificate of Workers Compensation ;d'Insurance
or a certified copy thereof (Sec 3800 lab C ) CQUNTY OF LOS ANGELES
w a BUILDING AND SAFETY
BUIL -
Policy No Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS ,�
Certified copy is filed with the county building inspec BUILDING w�T
tion department ADDRESS r LOCALITY
.j- NEAREST
Date Applicant CITY / / e ZIP 9/ LAO CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS / NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT ,SD NOW ON LOT MAP BOO PAGE PARCEL��
(This section need not be completed if the permit is for-one + U O MAPc��,� f
hundred dollars ($100)or less ) TRACT BLOCK LOT NO r NO
t p ) 0 TEL —y / SPECIAL IL
I certify that in the performance of the work for which this OWNER /",R MRS// /� //��}a�/ONO 6 / CONDITIONS IL
permitis issued I shall not employ any person in any manner rr�� I TRICT GROUP TYPE FIRE PR ESSED BY M 0
ADDRESS SeI2- CONST _Z
so as to become subject tq the Workers CompensQtion aws �,n a,
ONE
CITY �/I I /� - / ZIP
Date Applicant STATISTICAL CLASSDItATION AW CONDO U
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL
Exemption you should become subject to the Workers ENGINEER NO CLASS NO DWELL UNITS d
Compensation provisions of the Labor Code you must forth ADDRESS - SEWER MAP
with comply with such provisions or this permit shall beZ
deemed revoked CONTRACTOR NO BTEL o PG / VALIDATION
LICENSED CONTRACTORS DECLARATION I
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS // LC C VALUATION
(commencing with Section 7000)of Division 3 of the Business and c LIC
Professions Code and my license is in full force and effect CITY CLASS $
SQ NO OF NO OF CHECK
3 0
SIZ 2 ST RIE FAMILIES ONE 3+9 A
License Number Lic Class ��yy��� ..-- �'� ,-
DESCRIPTION OF WOR s. NEW $❑ �`J�v
Contractor DateADD o o o o 23
t t
F1 !I am exempt under Sec °� ALTER FINA 2 0 15300
8 8P C for this reason t ❑ DATE.
REPAIR
Date DEMOL ❑ -FI t i r o o D d 35
Signature APPLICANTt TEL By 0727-84
- OWNER BUILDER DECLARATION PRINT _ _a_ _NO _ _ _ ^
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and ADDRESS - 379 6 A
scions Code) PRESENT
BUILDING a.. � � o 0 0 0 23
1 as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section LOCALITY < 2�O 9
7044 Business and'Professions Code) MOVING TEL + o o 1 40 9 0�
I as owner of the property am exclusively contracting CONTRACTOR NO - 0 2 — Q 4
with licensed contractors to construct the project (Sec ADDRESS
8
tion 7044 Business and Professions Code) 9,379 7 A
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LIN WIDTH
I hereby affirm that there is a construction lending agency for FRONT — _ , $ 0'0 a o o
the performance of the work for which this permit is issued P L ` * q t 1
(Sec 3097 Civ C ) SIDE _ o
PL _ � - _ ;2! 356,25
Lender s Name �, _ � a 3 5 6 2 5
z ;
P C Fee$ Permit Fee -_ '
Lender s Address f ' rt0 2 27-84
`
I certify that I have read this application and state that the � C P Issuance Fee V
above information is correct I agree to comply with all County Investigate e t
g ordinances and State laws relating to building construction �Total fee a� is
b and hereby authorize representatives of this County to enter
upon the above menti o ed property for inspection purposes t -
&aa/�LC� �-27jq�.. } SEE REVERSE FOR EXPLANATORY LANGUAGE
Agent Signature of Applicant or Agt Date v ®t