HomeMy Public PortalAbout4846 AGNES AVE_Building_7/6/1989_ADD 1 BEDROOM 1
.-ORKERS, COMPENSATION DECLARATION
+ereby affirm that I have a certificate of consent to self x APPLICATION FOR BUILDING P E RM I T
i�sure or a certificate of Workers Compensation Insurance
o .a mersfied copy thereof (Sec 3800 Lob C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poll y f4aAma—Company BUILDING
(R Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec BUILDING /
Tion department / ` ADDRESS O
Date4 - Applicant & CITY ZIP LOCALITY
1 NO OF BLDGS � NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT S NOW ON LOT CROSS ST
COMPENSATION INSURANCEr
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOORK PAGE PARCEL
hundred dollars ($100)or less ) TEL
OWNER NO USE ZONE MAP Er
I certify that in the performance of the work for which this NO r
permit is issued I shall not employ any person in any manner ADDRESS - SPECIAL r o.
x ' CONDITIONS O
so as to become subject to the Workers Compensation Laws ., C)
.% CITY Q-414 ZIP a
Date Applicant ARCHITECT OR TEL r DISTRICT OUP TYPE FIRE PROCESSED BY V
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO CONST ZONE
Exemption you should become subject to the Workers AA ? +y
Compensation provisions of the Labor Code you must forth ADDRESS ..3 �J N
with comply with such provisions or this permit shall be TEL 243 �-7 STATISTICAL CLASSIFICATION APT CONDO Z
deemed revoked,, CONTRACTOR
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS
-
LICENSED
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS k4rl omie
4,Lp NO SAC IZ SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC
and Professions Code and my license is in full force and effect CITY CLASS BK PG VALIDATION
SQFT NO OF NO OF CHECK
License Number Lic Class_ SIZE STORIES FAMILIES ONE
^ ,�/ VALUATION 4
Contractor kerb /{'J �Date (7 DESCRIPTION OF WORK NEW j❑
/ $
ADD
❑I am exempt under Sec
_ ALTER popt
B&P C for this reason $ i
REPAIR ❑
Date USE OF
EXISTING BLDG DEMOL ❑
Signature �"��'��O APPLICANT TEL ! FINAL
OWNR B YI DER DECLARATION (PRINT) e' Les NO O
1 hereby affirm that I am exempt from the Contractor s License ADDRESS 2 ~
DATE 11
17#T
Law for the following reason (Section 7031 5 Business and FI _
Professions Code) .- PRESENT Y K= A
BUILDING t r AM T
a ❑ 1 as owner of the property or my employees with ADDRESS _ t T �s I j S e4 ``tom :,
wages as their sole compensation wil I do the work and ' �.k) 14 r 0307; 209 29
the structure is not intended or offered for sale(Section LOCALITY 1 1 �
7044 Business and Professions Code) MOVING - TEL + t l r
CONTRACTOR NO
❑ I as owner of the property am exclusively contracting �+ , L If A� 209.25
with licensed contractors to construct the project (Sec r y"� AL `1n
tion 7044 Business and Professions Code ) ADDRESS a ,- _3 a �y +y"i� V"�• # CHRK 207 29
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH ru�trCI
I hereby affirm that there is a construction lending agency for FRONT + J 411tt1'iVG
the performance of the work for which this permit is issued P L
(Sec 3097 Civ C) ] ��� SIDE + t
Lender s Name Lta NAH t y P L - Onr� -0001 7Mf 689
��e P C Fee S P m t fee299
LDMA Ref # SVut 8V �1 AI l 11 �Fq
Lender s Address -�`� y ► 'K�
c I certify that I'Rove read this application and state that the Iss o ce Fee d LDMA P/C# ^
8 above information is correct I agree to comply with all County I e t gat on Fee ````
ordinances and State jaws relating to building construction Total Fe V LDMA Pe m #
and hereby authorize representatives of this County to enter
upon the above mention erty for inspection purposes
r
SEE REVERSE FOR EXPLANATORY LANGUAGE
e
g of o App a t o Age t Date a+ S