HomeMy Public PortalAbout4844 ALESSANDRO AVE_Building__ ---- ..........— �• ;
p ATION DECLARATION
aft e r certificate of consent to self APPLICATION FOR BUILDING 'PERMIT
ns e, 5�c ;'f Workers' Compensation Insurance, 'r}<
or a certified copy tt�f (Sec. 3800, Lab C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. �Company ' ' '�S ^„ ylv+`•t'
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Certified copy is heiel;f�uMntshecf r' r rn r f BUILDING
FOR APPLICANT TO FILL IN ADDRESS70
Certified copy is filed wFfn"ine Bounty building inspec- BUILDING 7 F/J� L �.
tion department. ADDRESS 77
Dote ����ZApplicant CITY M �w✓i� Gf ZIP r� LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
�^ TEL. USE Z NE MAP _ �—
I certify that in the performance of the work for which this OWNER L�� c� rte : NO. g-�/ rF� NO.
permit is issued, I shall not employ any person in any manner �i SPECIAL
ADDRESS ✓9'LS /V CONDITIONS
so as to become subject to the W s'Compens 'on lows. ^ p, Q
4t-e7 CITY .7a e&�A,& C/ ZIP [,17 U
Date Applicant O`
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR��77 S TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers'
ENGINEER 12 � U�N �O• CONST. ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS � 'V - W.
with comply with such provisions or this permit shall be O."
deemed revoked. TEL. STATISTICAL CLASSIFI ATION APT. C N
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed 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 J VALIDATION'
SQ. FT. NO. OF i NO. OF / CHECK
License Number Lic.Class SIZE STORIES FAMILIES 1 ONE
- VALUATI N
Contractor Date DESCRIPTION OF WORK FAM I L � NEW ❑ $
�0
I am exempt under Sec. �QM ADD v , # 0 0 � 0 9 9
ALTER 3
B.BP.C. for this reason S� REPAIR ❑ $ 1 - 279,87
USE OFnn s
Date: EXISTING BLDG. t� DEMOL ❑ o ° 2 7 9.8 7 5
Signature APPLICANT L EOL FINAL 0 6 0 4'`8 7
PRINT i�� S✓v NO. j
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License d/3—
Law for.the following reason (Section 7031.5, Business and ADDRESS �� — FIN
Professions Code): OM
PR ENBY
BUILDING 7 r
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work andM1
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). 7 6 5„� A
REQUIRED TOTAL SETBACK FROTM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT #,a 0 a •'0,1
the performance of the work for which this permit is issued P.1. �i( 0 339.75
(Sec. 3097, Civ. C.). SIDE
P.L -
Lender's Name r 0 ®3 3 9.7 5 C
( LDMA Ref. #
P.C. Fee s Permit Fee _ p2,••} Q a.q 21t
B7
Lender's Address _ ' O 1
3 I certify that I have read this application and state that the
o Y PP Issuance Fee � r J LDMA P/C# -
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee 3 LDMA Perm. #
and hereby authorize representatives of this County to enter
m
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Age-nt Date