HomeMy Public PortalAbout5036 ALESSANDRO AVE_Building__ WORKERS' COMPENSATION DECLARATION
insure,hereby
certif caste of Workers' Compensationve a certificate of nt to self
Insurance, APPLICATION F O g 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 r ) ADDRESS3r/o
❑ Certified copy is filed with the county building inspec- BUILDING
ADDRESS V /V I/
tion department.
CITY' '/_/ ! lam/ ZIP ( LOCALITY
Date Applicant N . OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT NEAREST
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.) OWNER ) EL- p�/� �p� SE ZONE MAP
G �O(i' NO. O �'S� OC NO.
I certify that in the performance of the work for which this ,( ,/y�y� )� SPECIAL }
permit is issued, I shall not employ any person in any manner ADDRESS 4jALI /O/� J( 7&lam,/� 1 CONDITIONSCL
so as to become subject to the Workers' Compensation Laws. CITY ' �� �/ ZIPc//(l I /y,� O
Date Applicant ARCHITECT OR TEL. (j IJ DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. E U
Exemption, you should become subject to the Workers' Q , / w
Compensation provisions of the Labor Code, you must.forth- ADDRESS �CJ 3 V1'r
N
with comply with such provisions or this permit shall be ) TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR lJ`�Ic C/e�• NO. —
LICENSED CONTRACTORS DECLARATION . LIC. CLASS NO.1--�Z DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is,in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lica Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑ s
�b
ADD ►❑
❑I am exempt under Sec. ALTER ❑
B.BP.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
APPLICANT EL.
Signature (PRINT) l4 C � O. 2 JNAL JJJ ;l-
PRINT G�
Rig
OWNER-BUILDER DECLARATION DATE Z
hereby affirm that I.am exempt from the Contractor's License /
Law for the following"reason (Section 7031.5, Business and ADDRESS FINAL _
Professions Code): PRESENT BY =# `r'
BUILDINGKL 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 ,
( MOVING TEL.
7044, Business and Professions Code.) H:_•� •• „
CONTRACTOR NO. ;'•�_;_:;{ 'i;' ;_,;;
I, as owner of.the property, am exclusively contracting a.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) =-• ``"
CONSTRUCTION LENDING AGENCY SETT REQUIRED
YARD HWY TOTAPROP. LISETBACNE WIDTH JE
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. t„i; w• i;K '. f j. :,-`';',.
(Sec. 3097, Civ. C.). �' f SIDE _ _
LJ P.L. _ x
Lender's Name . A Ref. #P.C. Fee$ Permit FeeLender's Address 1 certify that I have read this application and state that the Issuance Fee A P/C#
above information is correct. I agree to comply with all County Investigation Feerordinances and State laws relating to building construction, Total Fee. A Perm. #
a and hereby authorize representatives of this County to enter
upon t a ove-menti ned property for inspection purposes.
a
• '� -� Dote � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agen