HomeMy Public PortalAbout5822AGNES AVE_Building (3) WORKERS' COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self APPLICATION FOR WILDING P E RM I T
insure, or a certificate of Workers' Compensation Insurance, .
or a certifieded cof (Sec. 3800, Lab. C.) A/ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No� Company
❑ 'Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
copy y ADDRESS d
Certified copy is filed with the county building inspec- BUILDING �xIE25
tion depart nt. ADDRESS
Dat Applica J CITY" "!l ZIP LOCALITY
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE / ASSESSOR
(This sec need not be completed.if the permit is4or one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred do ($100) or less.) TEL.
OWNER N � USE ZONE. MAP
I certify that in the formance of t ork for which this NO.
permit is issued,,I shall n em to person in an manner ADDRESS ��.�� SPECIAL
P P Y Y P Y CONDITIONS O
so as to become subject to orkers' Compensation Laws. �� U
CITY X��P� C J ZIP. r/ v
Date pplicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APP ANT: If, after maki this Certificate of ENGINEER , �� �. NO. CONST. ZONE V
Exemption, u should become subject the Workers'
Compen ion provisions of the Labor Code, y must forth- ADDRESS �(10 I� A �J a
with omply with such provisions or this permit all be a ��,,j E�L. ��,s� TATISTICAL CLASSIFICATION APT. CONDO. N
erred revoked. CONTRACTOR ;� JOl�L� OA(Jtl6. 7�Y % Z
LICENSED.CONTRACTORS DECLARATION �J� «igl, LIC. /�, ' CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS CZ O�`�— NO. Yl��e SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Cod ,and my license is in full force and effect. CITY ��117�rJ}y �i� CLASS BK PG VALIDATION
SQ. FT. NO. O NO. OF CHECK
License Number �,[Liic'. �C,lla'ss SIZE STORIES FA/MILIES ONE
Coniractar��I�C/�i�h1/1r/�te7��`ll�cs DESCRIPTION OF WORK XCV(; , NEW VALUATION 00
❑I am exempt under Sec.
�/ /G� /�G ADD ❑ ►
,Q �f ALTER ❑
BAP.C. for this reason /�T�a� ��� REPAIRUSE OF
❑ $
Dat EX TING BLDC�N51AN�Ze L G�C5 DE/M�OjL�❑
S gnat 1/llwtw/L APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT) 72K91-�'IA.S 1- SNO.
I here affirm that I am exempt from the Contractor's Li nse L�i, � DATE� � 1 � •�
ADDRESS/�GQ / �D1/� FINAL �"� �''"'"
Law for he following reason (Section 7031.5, Busin s and � /�yly/r AC.{ nT
Profession Code): PRESENT BY /11
BUILDING
El I, as o er'of the property, or my a ployees with ADDRESS
wages as eir sole compensation,w' do the work and ��
The structure off not intended or oed for sale(Section LOCALITY
7044, Business rid Professions ode.) MOVING TEL. eT�
E] 1, as owner of th roperty, m exclusively contracting CONTRACTOR NO.
with licensed contr tors o construct the project (Sec- ADDRESS '�l'){ r~r't•'
tion 7044, Business a Professions Code.)
REQUIRED TOTAL SETBACK FROM JE =3=11
CONSTRUCZ! N L ING AGENCY. SET BACK YARD HWY PROP. LINE
I hereby affirm thW.ttkn e is a cons uction lending agency for FRONT TOTAL ITAL 14 1 n s
the performancee work for w h this permit is issued P.L. iJ(Sec. 3097, Civ. SIDE :t« is ilo_C
P.L.
��I•
Lender's N m, A Ref. # C• TGE�.P.C. Fee$ Permit FeeLnde s Address
�1
crtifythatIhave read this application and state t t the Issuance Fee A P/C# i''`'"above information is correct. I agree to comply with all Co ty Investigation Fee 4 •1,ordinances and State laws relating to building construction, Total Fee / A Perm. # ' ' 'it
a and hereby authorize representative of is County to enter
upon thea ove-men' ed pr r f spection purpose .
91 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applican or nt Date