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HomeMy Public PortalAbout5019 ALESSANDRO AVE_Building__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy � "cJ' Company �G BUILDING rfified copy is hereby furnished. FOR.APPLICANT TO FILL IN ADDRESS 11 �U d--Zertified copy is filed with the count bu' ng inspec- BUILDING tion department. ADDRESS LOCALITY /J) NEAREST Date r oC � pplicanf!'� / CITY ZIP CROSS ST. CERTIFICATE OF EXEMPTION FR W RKE ' NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if.the permit,is'for one USE ZONE MAP hundred dollars ($100),or less.) TRACT BLOCK LOT NO. NO. Zork TE ) // SPECIAL } I certify that in the performance of the which this OWNS N ac 1 CONDITIONS �� DISTRICT GROUP TYPE_ FIRE PR SSED BY O permit is issued, I shall not employ an person in any manner ADDRESS CONST. _„ ZONE so as to become subject to the Wo ers'Compensation Laws. �q,� If Date APel' ant CITY / t ZIP STATISTICAL ASST KATION J APT. CONDO. NOTICE TO APPLICANT�,:� after making this Certificate of ARCHITECT OR TEL. 'ZI LU Exemption, you shovt-d become subject to the Workers'' ENGINEER O. CLASS NO. DWELL. UNITS Compensation pro ' ions of the Labor Code, you must forth- ADDRESS ) ©� SEWER MAP with comply w' such provisions or this permit shall be 'TEL. VALIDATION deemed revo d. abA JC' NO BK. PG, CENSED CONTRACTORS DECLARATION LIC. I hereb affirm that I am licensed under provisions of Chapter 9 ADDRESS -J6 e 1 N VALUATION (com encing with Section 7000)of Division 3 of the Business andLIC Pro essions Code, and my license Js in full force and effect. CITY CLASS $ a ► SQ. FT NO.bF NO.OF CHECK License N be r Lic.Class SIZE t'J, STORIES FAMILIES ONE S NEW $ / DESCRIPTION OF OR ontract r ® it �� 3.5 O A s I am exempt under Sec. ADD �� �� L - LTER FINAL/ J � #io 0 0 0 0 1 DATE (� B.BP.C. for this reason 1 C/ - r � PAIR '2.0 a,b 8 b 3 s USE OF /'„/ FINAL _: Date: EXISTING BLDG. ► (J DEMOL , Signatures APPLICANT' TEL. By '° ° ° b 6 3 0 OWNER-BUILDER DECLARATION PRINT --- NO(` I hereby affirm that I am exempt from the Contractor's License r �r `, �/�� 0 7. 1 2-8 73 Law for the followingreason Section 7031.5, Business arfd ADDRESS Professions Code): ( "� PRESENT `3.5 a 1 A BUILDING I, as owner of the property, or my a oyees with ADDRESS o 0 0 0 2 3 wages as their sole compensation,wi4 o the work and t the structure is not intended or offered for sale(Section LOCALITY f1 0'0 o a 2 3 7044, Business and Profess ionsXacle). MOVING TEL. CONTRACTOR NO. �. I, as owner of the proper��am exclusively contracting 2 ° ° 4 9.4 1 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business arfd Professions Code). o'o o-!.9.�I 1 c=i REQUIRED TOTAL SETBACid CONSTRUCTION'LENDING AGENCY SET BACK YARD HWY PROP. LIc I hereby affirm that lucre is a construction lending agency for FRONT 7'1 21-83 the performancefof the work for which this permit is issued P.L. (Sec. 3097, Ciy/C.). SIDE FO P.L. e Lender's Name $ P.C.Fee$ Permit Fee _ Len is Address ertify that I have read this application and state that the Issuance Fee above information is correct 1 agree to comply with all County InvesstigationFee $ ordinances and.State;laws rel ting to building:construction,i Total.Fee,and hereb a res ritatives of this County to enter ypo a above- enti' ed roperty for,inspectionpurposes. SEE,REVERSE FOR EXPLANATORY LANGUAGE ' ignatu a of A46ficant or nt Date ®s