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HomeMy Public PortalAbout5822AGNES AVE_Building (4) WORKERS COMPENSATION DECLARATION (� ` ti 77- hereby 7 nsure bor a certificate of Worke srtificate of Compens consent Insurance 41 } APPLICATION FOR BUILDING PERMIT a certified cop there f(mac 3800 Lab ) P y 111 *zf� 'fi `T U anys' n^s 5 s COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified co is hereby furnished c© � BUILDING Pv v 'FOR APPLICANT TO FILL IN ADDRESS �►C� Certified copy is filed with the county building inspec BUILDING 1 ❑ +tion deportment _ 6 ADDRESS 6715:v—7— LOCALITY �� � �` G . Date Applicant CITY ZIP CROSSNEARESTR—K wn-V CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one TRACT BLOCK LOT NO USE ZONE MAIr — © )� NO hundred dollars ($100)or less ) i, TEL �, SPECIAL I certify that in the performance of the work for which this OWNER NO CONDITIONS permit is issued I shall not employ any person in any manner (% Z DISTRICT GROUP TYPE FIRE PROCESSED BY O so as to become subject to the Workers Compensation Laws ADDRESS 7v` /+C7N� � CONST ZONE tl U {-�-- r Im CITY Date Applicant I L� ZIP ARCHITECT OR TEL STATISTICAL CLASSIF TION �� APT ONDO 0 NOTICE TO APPLICANT If after making this Certificate of 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 N with comply with such provisions or this permit shall be Z deemed revoked CONTRACTOR jc,*N EL V�/1 BK PG VALIDATION LICENSED CONTRACTORS DECLARATION ��V�" � LIC y r�L24r� I hereby affirm that I am Icensed under provisions of Chapter 9 ADDRESS Gy N VALUATI N (commencing with Section 7000)of Division 3 of the Business and A ,e.L LIC Professions Code and my license is in full force and effect CITY Sim IPTG CLASS Y $ Q ^ SQ FT y [�'7' NO OF NO OF CHECK CLicenseNumber�l22/j'��'`Lc Class—F, SIZE 4✓ STORIES FAMILIES ONE ConfracTotQ 6n :. Date DESCRIPTION OF WORK / NEW ❑ $ Its ❑ I am exempt under SecAIf 41 C� ADD ALTER ❑ FINAL p (}C�4,,4 A V REPAIR DATE Z_❑ Z—(! ¢- B 8P C for this reason # o o e o o '� Date USE OF A n _ EXISTING BVA—N� LDG DEMOL ❑ FINAL L o - 7800 Signature APPLICANT TEL flMFUr _ OWNER BUILDERpDECLARATION y PRINT G ��_ l�Q p - to 0 0 78 0 0 v I herebyaffirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and ADDRESS ' 0 28'-83 Professions Code) PRESENTj ❑ 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) 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 �f pROP LINEWIDTH 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 m PL ' a Lender s Name Lender s Address PC Fee$ Permit Fee �'I'certify that I have read this application and state that the Issuance Fee (l► S above information is correct I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction Total Fee �O V b nand hereby authorize representatives of this County to enter upo a above me coned property for inspection purposes ^ f/01 SEE REVERSE FOR EXPLANATORY LANGUAGE /Afgnature of Applicant or Agent i R ®s r I