HomeMy Public PortalAbout5031 ALESSANDRO AVE_Building__ WORKERS' COMPENSATION DECLARATION
`I `herebo 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 No. Company
BUILDING
❑ Certified copy is hereby furnished._ FOR APPLICANT TO FILL IN ADDRESS J
❑ Certified copy is filed with the county building inspec- BUILDING
RESS SO S�
tion department. ADD
—re r11
Date Applicant CITY ZIP a�(J LOCALITY
NO. OF BLDG& NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL.
OWNER Lj� USE ZONE NOP i
I certify that in the performance of.the work for which This SPECIAL }
permit is issued, I shall not employ any person in any manner ADDRESS. J CONDITIONS a
so as to become sub'ect to the Workers'Compensation Laws. Q
,,n( � CITY ZIP
DaT �v r Applicant f^"- ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after .making this Certificate o ENGINEER NO DIS RICT GROUP TYPE FIRE PROCESSED BY
CONST. ` / ZONE U
Exemption, you should become subject to. the Workers- ® y � C� p U
Compensation provisions of the Labor Code, you must forth- ADDRESS 'J LU
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO.
a -LICENSED CONTRACTORS DECLARATION LIC. CLASS N '@„ADWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES N
(commencing with Section 7000)of Division 3.of the Businesstj
C. SEWER_MAP C,
and Professions Code,and my license is in full force and effect. CITY CLASS BZ Z X VALIDATION
SO. FT. NO. OF NO. OF CHECK UU
License Number Lic. Class SIZE I STORIES FAMILIES ONE
VALUATION
Contractor 'Date DESCRIPTION OF WORK NEW ❑ ��
'
❑I am exempt under Sec. e :� ADDIED oil.� '
ALTER ❑
B.&P.C. for This reason REPAIR $
Date: USE OF.
EXISTING BLDG. DEM
Signature APPLICANT TEL FINAL
—7�j�
l
OWNER-BUILDER DECLARATION (PRINT) V O. b C/Dr
DATE
Iv
I hereby affirm that I am exempt from the Contractor's License ��(j
Law for the following reason (Section 7031.5, Business and ADDRESSS01 e P FIN
Professions Code): PRESENT • By
BUILDINGI, as owner of the property, or my employees with
ADDRESS ACCT,
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY jp �O
7044, Business and Professions Code.) MOVING TEL.
J+JiJ J 7 7.83
CONTRACTOR NO.❑ I, as owner of the property, am exclusively contracting 1 ITEMS
with licensed contractors to construct the project (Sec- PADESS TOTAL ® �
tion 7044, Business and Professions Code.) - nL
UIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY BACK YARD HWY PROP. LINE WIDTH CHECKe Vii;
I hereby affirm that there is a construction lending agency for NT el �
the performance of the work for which this permit is issued CHANGE I
(Sec. 3097, Civ. C.).Lender's Name �,L�/ �LDMA Ref. # 281 8ee$ Permit Fee JLender's Addressr1 �3JI �' l1'�,I33
1 certify that I have read this application and state That the Issuance Fee V LDMA P/C#above information is correct. I agree to comply with all County igation Fee
ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
a an ereby authorize re resentatives of this County to enter
�� u ri t abov 4tLon d opert for inspection purposes.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date