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HomeMy Public PortalAbout5049 ALESSANDRO AVE_Building__ WORKERS' COMPENSATION DECLARATION insure,or°a certif cane of Workers' Comtpensat ons Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Po4cy No//047R10`Mmpany 5;-13ic e0 11DeP.SNTI0A 1��+ G• l^!3/11! BUILDING ❑ Certified copy is hereby furnished. .i _�� FOWNER ,/ FOR APPLICANT TO FILL IN ADDRESS �O - ,CE ❑ Certified copy is filed with the county building inspec- L tion department. / SSSS 6 f, t Date-J-26-9 Applicant !�n���T `/��'�2 OG �- j ZIPLOCALITY If NO. F BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' O q NOW ON LOT f CROSS ST. COMPENSATION INSURANCEASSESSOR(This section need not be completed if the permit is for one BLOCK LOT NO. MAP BOOK O / PAGE `� PARCEL�49/ hundred dollars ($100) or less.) TEL.U /'itJZ Z�TT) NO. USE ZONE NO, y oZ I certify that in the performance of the work for which this n / SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS Sa y /�L c S !�!J(�2G� �Gc / CONDITIONS so as to become subject to the Workers'Compensation Laws. T r O CITY � 1 T� � -r ZIP U Date Applicant ARCHITECT OR TEL. �� � 1 DISTRICT �CUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER l/� oA► 1 O MN CVU NO.<. a0 t7�5�) CONST. ZONE t- ' Exemption, you should become subject to the Workers' U uJ Compensation provisions of the Labor Code,you must forth- ADDRESS Jr2 Z J, A/Z }` _( 10 Y. ��d ,! 9 1L� a0- with comply with such provisions or this._permit shall be L TEL. t Sr STATISTICAL CLASS�ON APT. CONDO. Oz deemed revoked. CONTRACTOR �i9riJl2 C'� a•L3 �NO. F 4 9�r/j Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS f 1 U 4 /4 L tg.4 �_ NO. (commencing with Section 7000)of Division 3 of the Business /� LIC. SEWER MAP and Professions Code,and my license is in full•force and effect. CITY /r,��; l(jL�i�Uf4 CLASS & BK.�PG.� VALIDATION SQ. FT. NO. OF NO. OF CHECK . License Number �/ /"13 Lic. CI6ss SIZEZ� STORIES FAMIUES _ ONE �+ ❑ VALUATION Contractor Zr-F,O/L eilx-tom L 64-Sate .1 l0 fZ S I TI NOF WORK"�O D EW R �3o-�3DD � $o?� � , ❑I am exempt under Sec. L !�"� , E-L ALTER ❑ B.BP.C. for this reason /� f?O U� REPAIR ❑ $ Date: USE OF EXISTING BLDG. i snJ DEMOL E-1 Signature APPLICANT p TEL. FINAL OWNER-BUILDER DECLARATION (PRIN7j l�c(jt72'i �t�/ -yCC�O, �f i L) "g�y5' I hereby affirm that I am exempt from the Contractor's License _ DATE Law for the following reason (Section 7031.5, Business and ADDRESS !� � /-71G�l / ! �al /��� FINAL 0 " Professions Code): PRESENT p / ByILDIN _ f4 ❑ I, as owner of the property, or my'employees with ADDRESS ©L// �" -'` Al�l�� �CJ ty i�31, • wages as their sole compensation,will do the work and LOCALITY �� L the structure is not intended or offered for sale(Section 7 E - 7044, Business and Professions Code.) MOVING / TEL. CONTRACTOR NO. ❑ I, as owner,of the-property, am.exclusively contracting "' "'"` ' with licensed contractors to construct the project (Sec- °? "€•a= ADDRESS tion 7044, Business and Professions Code.) i i ; REQUIRED YARD TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING RD HWY AGENCY SET BACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT �St ,tryr":•.;: - y,.: the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE Ze v �it1 zETT/ P.L. Z Lender's Name. LDMA Ref. # x P .C. Fee$ Permit Fee i G } 3 Lender's Address I certify that I have read t is applicatio.�q// nd"state that the Issuance Fee LDMA P/C# above information is correct. I agree to comply with all County estigation Fee - 8 ordinances and State laws relating to building construction, Total Fee i 4 LDMA Perm. # a and hereby authorize representatives of this.County to enter upon thea bove-m ntioned property for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date