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HomeMy Public PortalAbout5822AGNES AVE_Building (2) rt WORKERS COMPENSATION DECLARATION .0 1 hereby affirm that I have a certificate of consent to Self "APPLICATION FOR BUILDING PERMIT insure or a certificate of Workers Compensation Insurance or a certified coy Pf ((_Sec 3800 Lab C ) Policy No3© � Company �d(G1 [(�'� COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county b ding inspec BUILDING 5— BUILDING tion spar ant ADDRESS �Jr-8 ZIF 2�1 C ' LOCALITY kry Date Applica CITY I CROSSSST (�/ RTIF ATE OF EXEMPTION FROM WORKERS NO#OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT s MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for oneh U E ZO MAP hundred dollars ($100)or less ) TRACT BLOCK LOT NO I NO Zo I TEL SPECIAL } I certify that in the performance of the work for which this OWNER 7 NO CONDITIONS IZ permit is issued I shall not employ any person in any manner �r DISTRICT GRA TYPE FIRE PROCESSED BY O so as to become subject to the Workers Compensation Laws ADDRESS P C>Z-�� �/✓ a� t CONST ZONE V �T,V _ 3 0 CITY Date r Applicant ZIP STATISTICAL CLASSIFICATION APT CONDO 0 NOTICETO APPLICANT If after making this Certificate of ARCHITECT OR � �� Exemption you should become subject to the Workers ENGINEER NO CLASS NO DWELL UNI1_!_e_5 Compensation provisions of the Labor Code you must forth SEWER MAP with comply with such provisions or this permit shall be deemed revoked �, TEL BK PG VALIDATION CONTRACTOR LICENSED CONTRACTORS DECLARATION a I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS/Alto ,� I. d.4 NO ) J')" VALUATION coo (commencing with Section 7000)of Division 3 of the Business and LIC Professions Code and my license is in full force and effect CITY CLASS $ p�O SQ FT NO OF NO OF CHECK License Number �' 1J' Lic Class SIZE STORIES IFAMILIES ONE Contract"a it'14 . .V D Date DESCRIPTION OF WORK ❑ $ NEW �5443N ADD El 0 0 0 0 0 I am exempt under Sec11;4, © r ALTER FINAL /� 2i° ° 4 Q 5 B&P C for this reason r REPAIR ❑ DATE ( ? 00040507: Date USE OF DEMOL ❑ FINAL .I'D 1 2—8 3 EXISTING BLDG By Signature APPLICANT C:�7,•,,A� W EL OER DECLARATION PRINT � fNO �.J 1 hereby off at I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and ADDRESS O Professions Code) PRESENT BUILDING I 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 7044 Business and Professions Code) I MOVING TEL I 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) REQUIRED TOTAL SETBACK FROM EXIST 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 ) SIDE io P L e Lender s Name $ Lender s Address P C Fee$ Permit Fee o�c I certify that I have read this application and state that the Issuance Fee a above information is correct I agree to comply with all County Investigation Fee n ordinances and State jaws relating to building construction Total Fee V� d and hereby auth a representatives of this County to enter upon th obo entioned property for inspection purpos a � GT SEE REVERSE FOR EXPLANATORY LANGUAGE Sig tura of Applicant or Agente ®s