HomeMy Public PortalAbout4845 ALESSANDRO AVE_Building__ WORKERS'COMPENSATION DECLARATION 850426 BG -
hereby
tI have ks'` naf consent
of WoreCompessuran , APPLICATION FOR BUILDING PERMIT
ora certified
copy thereof (Sec. 3800, Lab. C.') COUNTY OF LOS ANGELES BUILDING.AND SAFETY
Policy No.IV85-22515&mpany Fremont Indemnity
❑ -
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy'is'filed with the county building inspec- BUILDING
Tion department. ADDRESS 484 . Alessandro
Date-9/9/85 " ApplicantV I rg i n ROOF Co. CITY Temple City ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' -NO. OF BLDGS. - NEAREST
COMPENSATION INSURANCE - 1''•� 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 PA E. PARCEL
- OWNER - Geraldine G 1 1 da - NO: M
USE ZONE AP
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any manner ! ' SPECIAL,
ADDRESS as above
so as to beCONDITIONS come subject to the Workers'Compensation Laws. �� 0
Date Applicant .CITY... ZIP . . _
NOTICE'TO-APPLICANT: If, after.making`this Certificate of ARCHITECT OR TEL. DISTRICT_, GROUP TYPE.. FIRE PRO SSED BY
ENGINEER NO. CONST. ZON
Exemption, you should become subject-to the Workers' t j— r�
Compensation provisions of the Labor Code, you must forth- ADDRESS — LA,
LAM
with comply with such provisions or this-permit shall be - -
deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. C O.'
CONTRACTOR V i r 1 n Roof CO. NO. 287-0507 _
LICENSED CONTRACTORS DECLARATION ---LIC,- CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 1 666 0 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC. -
Professions Code, and my license is in full force and effect. CITY San Ga b r i e F CLASS C39- BK ' PG VALIDATION-
SQ. FT, NO. OF NO.•OF , CHECK
License Number 1 60650 Lic.Class C39 SIZE STORIES IFAMILIES ONE
pp VALUATION
Contractor V i rg i n ROOF CO.Date 9/9/85 DESCRIPTION OF WORK' NEW -- ❑
. - a 1558.00.
.garage with Class A fiberglass. ADD ElI am exempt under Seca ` ' ❑
ALTER
B.BP.C. for this reason comp. shingles. 19 1/2 sqs• REPAIR ❑ $"
USE OF
Date: EXISTING BLDG. -dwelling DEMOL ❑ i
Signature APPLICANTTEL. 28 O Q FINAL 2 8 9.9 A
PRINT) Virgin ROOF CO• NO. 7— S
OWNER-BUILDER DECLARATION DATE: �3
1 herebyaffirm that I am exempt from the Contractor's License `�/ #'o o' o 0 0
Law for the following reason (Section 7031.5, Business and ADDRESS P.O. Box J, San Gabriel 91778 FINAL
-.49.88
Profess ians'Code): PRESENT By -
BUILDING
I, as owner of the property, or my employees with ADDRESS 8-6
wages os their sole compensation,will do the work and o'a a•4 9"8
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code).' - MOVING "TEL " 9 1 2--8 5
I, as owner of the property, am exclusively contracting. CONTRACTOR NO.
with-licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code). ADDRESS
REQUIRED TOTAL SETBACK FROMEXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for kFRONT
the performance of the work for which this permit is issued(Sec. 3097, Civ. C.).Lender's Name
39.38 LDMA Ref. #
ee$ • -- - Permit Fee-
Lender's Address
>
it I.certify that I have read this application and state that the - Issuance Fee 16. 0 LDMA-P/C#
above information is correct. I agree to comply with all County Investigation Fee "
ordinances and State laws relating to building construction, _ Total Fee - 4, .88 LDMA Perm. -
U and h reby authorize representatives of this County to enter
up he above-mentioned operty for inspection purposes.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
S'gn ture of Applicant or Agent - - -• Date