HomeMy Public PortalAbout4821 ALESSANDRO AVE_Building__ r
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, A P P L I`3/AT I O N F O R BDING PERMIT
or'►i certified copy theFeo��f (Sec. 3800, Lqb. ..) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pblicy No�Cffjjompony o
BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS �7^' �`•
Certified copy is filed with the c ty buildin mspec- [AUDDRE
DING
tion department. SS
Date �Applic nt /-r--o" , ZIP 79-2 LOCALITY
N . OF BLDGS. NEAREST
CERTIFICATE OF EXE N FROM WORKE OF LOT NOW ON LOT CROSS ST.COMPENSA ION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one T BLOCK LOT NO. MAP BOOK Ok a PAGE � PARCELeZ�hundred dollars ($100) or less.) EL' USE ZONE MAPER ' O,
1 certify that in the performance of the work for which this N0.-
FE
.
permit is issued, I shall not employ any person in any manner ADDRESS t _ PECIAL
CONDITIONS O
so as to become subject to the Workers'Compensation Laws. CITY T-1— Ir- 121
���v U
ZIP tJ
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TAPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If,' after making this Certificate of ENGINEER NO.
CONST.
Exemption, you should become subject to the .Workers' f ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS • LA
with comply with such provisions or this permit shall be. IF STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR '} O. /J�/
Z
LICENSED CONTRACTORS DECLARATION t�� LIC. CLASS NO.�DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS p01 f l No'..
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY (_G�S� CLASS BK P VALIDATION
SQ. FT. NO. OF NO. OF CHECK'
License Number 7C 4'////►�,��-L/ Lit`c. Class SIZE STORIES FAMILIES ONE VALUATION
Contract o�VS�M C�hISd fY� j�a- l '5 2 DESCRIPTION OF WORK NEW $ � �V=
❑I am exempt under Sec. ADD
�+ ALTER
B.&P.C. for this reason 3
�. C CSL 11n "*REPAIR ❑ S, C/Q'7S_
USE ate: EXISTING BLDG. DEMOL ❑ ., of �i> >. '° c,,'j,�;
Si natu e APPLICANT �'� TEL.
g (PRINT), ..{tltVh CS y1 NO. FINAL. ISf'�2
NER-BUILDE ECLARA DATE
I hereby affirm that I am exempt from the Contractor's License G' � `-
Law for the following reason (Section 7031.5, Business and ADDRESS 7/ r VCC���Ucr� of 1 FINAL
Professions Code): PRESENT By <t1 y
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 O�
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 PROP.'LINE WIDTH
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. s
(Sec. 3097, Civ. C.). SIDE
P.L. 1
Lender's Name,
mZ140 � LDMA Ref. #
O• Permit Fee
3 Lender's Address P.C. Fee$
0 1 certify that I have read this application and state that the Issuance Fee LDMA P/C#
8 above information is correct. I agree to comply with all County InvestigationFee /
6 ordinances and State laws relating to building construction, Total-Fee LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date