HomeMy Public PortalAbout4809 ALESSANDRO AVE_Building__ jWORKERS
COMPENSATION DECLARATION
~}r rel oraf r
Jertif cate of Workers rtCompensat on ificate of consent
Insurancef _ APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C ) '
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING `�5 G
ADDRESS O L
0 Certified copy is Bled with the county building inspec [ADDRESSILDING
tion deportment o 45-5 SAND I/ say C�7 L 9i7r�o
r
Date Applicant Y ,0 T ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE E OF LOT NOW ON LOT CROSS S7/_ ASSESSOR
(This section need not be completed if the permit is for one ACT Irl BLOCK LOT NO P BOOK PAGE PARCEL
hundred dollars ($100)or less ) _NER %i ��/V
TEL
LO� 21.3^ USE ZONE MAP
I certify that in the performance of the work for which this NO
permit is iss d I shall not employ any person in any manner ADDRESS SPECIAL��i CONDITIONS ,
so as to,ktec m ubject to the Worke
rs Compensation Laws Q
((� /4%Y iio �W Cz CITY F✓f1 �.►'( ZIP
Date Applicant-��� ARCHITECT OR TEL
NOTICE To A LICANT If after making this Certificate of ENGINEER NO DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exempt op y u should become subject to the Workers CONST ZONE U
Compen alio provisions of the Labor Code you must forth ADDRESS
with comply with such provisions or this permit shall be
deemed revoked r TEL STATISTICAL CLASSIFICATION APT LONDO (q
CONTRACTOR O�� NO
LICENSED
' Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO '7- UNITS
I hereby affirm that I am Icensed under provisions of Chapter 9 ADDRESS NO
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP
Professions Code and my license is in full force and effect CITY CLASS BK PG VALIDATION
SQFT NO OF NO OF CHECK
License Number Lc Class SIZE TORIES FAMILIES ONE
❑
OF WORK NEW VALUATION
DESCRIPTION
Contractor Date / n, $ ,
❑ ` / 1:4) ,�C &44 �� ADD ® Iloll
I am exempt under Sec ALTER ❑
B&P C for this reason /zavo REPAIR ❑ $
USE OF
Date EXISTING BLDG DEMOI ❑
APPLICANT TEL
Signature i FINAL
OWNER BUILDER DECLARATION PRINT Q All' NO Z/ - DATE
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and ADDRESSFINAL
Professions Code) BY
❑ BUILDING � 0 5 S 0 A
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 3` + r `/i 1 # e o *Is e
7044 Business and Professions Code) MOVING TEL .� f
54 as owner of the property am exclusively contracting CONTRACTOR NO + + + I e
l 9988
with licensed contractors to construct the project (Sec ti ,
tion 7044 Business and Professions Code) ADDRESS ~ + 1 9 9 8 8
SETT BACK TOTAL
SETBACK
LIINE WIDTH Y t
CONSTRUCTION LENDING AGENCY YARD HWY o e v
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 L ,0 8 2 9it 8 8
(Sec 3097 Civ C ) SIDE
PL u
Lender s Name
m 3 LDMA Ref a
Lender s Address PC Fee$ Permit Fee c �
j certify that I have r ad this application and state that the Issuance Fee (/ LDMA°P/C link
above mformab n is orrect I agree to comply with all County Investigation Fee
0 ordrnanc an St to laws relating to building construction r
Total Fee LDMA Perm H
and here y a rize representatives of this County to enter i
upon the bo entioned property for inspection purposes
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4 IV ��Z 7��1 SEE REVERSE FOR EXPLANATORY LANGUAGE
A6t.re"ofUV-phcant or Agent Date