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HomeMy Public PortalAbout5822AGNES AVE_Building (5) - , WORKERS COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self I ATI I• insure or a certificate of Workers Compenstion Insurance or AP P L C O ISI FOR B'U I L P E IOIIIT na certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company BUILDING ..- Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec BUILDING i (i 1 tion department ADDRESS LOCALITY NEAREST Date Applicant - CITY ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS OF 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 U Z.�vyMAP �) hundred dollars ($100)or less ) TRACT BLOCK LO LNO y may)[CONDITIONS SPOECIAL `/ OWNER NO / `, '� 0 1 certify that in the performance of the work for which this - DI4. STRICT GROUP TYPE FIRE ED BY permit i5 issued I shall not employ any person in any manner ADDRESS r /Q� y, CONST / Z C9 so as to become sublect to the Workers Compensation Laws (J Kms, OC Date Applicant CITY ZIP STATISTICAL CLAS541C�TION AIroNDO NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL : f�/S/TT W Exemption you should become subject to the Workers ENGINEER NO CLASS NO DWELL UNITS N Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP Z with comply with such provisions or this permit shall be U[/ 7 deemed revoked CONTRACTORof TEL NO 7 7d /�7b BK\ VALIDATION LICENSED CONTRACTORS DECLARATION LIC �} I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS `� (� NO O� 7 VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC n $ 0� Professions Code and my license is in full force and effect CITY CLASS rQ _ ern SQ FT NO OF NO OF CHECK License Number Lic Class T SIZE STORIES FAMILIES ONE r Contractor �—OW Date r DESCRIPTION OF WORK NEW ADD I am exempt from The licensing requirements as I am a licensed architect or a registered professional engineer ALTER FINAL, --, q� acting in my professional capacity (Section 7051 REPAIR DATE CJ Business and Professions Code) USE OF DEMOL FINAL EXISTING BLDG By �J Lic or Reg No Date APPLICANT TEL OWNER BUILDER DECLARATION (PRINT) NO I hereby affirm that I am exempt from the Contractor s License - Low for the following reason (Section 7031 5 Business and ADDRESS 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) MOVING TEL C r� I as owner of the property am exclusively contracting CONTRACTOR NO , �3 3 5 Y A with licensed contractors to construct the protect (Sec ADDRESS - .L tion 7044 Business and Professions Code) # o a o o i 1 REQUIRED TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH 2>0 0 O 6 of 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 , o e o``]0 0 0_ (Sec 3097 Civ C ) _ SIDE PL 1 Lender s Name r 0323-82 Lender s Address P C Fee$ ermit Fee y ' > I certify that I have read this application and state that the Issuance Fee above information is correct I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction ®r©® , and hereby authorize representatives of this County to enter oral Fee aupon the abo� mentioned property for inspection purposes -,e 1��►/Si_ /'�" ��� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ©s