HomeMy Public PortalAbout5538 ALESSANDRO AVE_Building__ 4
s RKERS COMPENSATION DECLARATION
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�rt insu-* or a certif carte of WoikersrtCompensai on Insuran elf APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING
Policy No (0!Q -0) Company tbkke- 1PkjAA A
Certified copy is'hereby furnished ' FOR APPLICANT TO FILL IN ADDRESS 3
Cert fled copy is filed with the county building mspec BUILDING `
tion department / ` ADDRESS v�
Date y Applicant v" CITY ZIP q LOCALITY
CE TIFICATE OF EXEMPTION FROM WO KERSNO OF BLDGS NEAREST 7J,�t
COMPENSATION INSURANCE SIZE OF LOT L( NOW ON LOT CROSS ST �(,�/
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less ) ° TRACT BOCK LOT NO MAP BOOK PAGE PARCEL
OWNER TEL USE NE MAP
I certify that in the performance of the work for which this �' NO — NO
permit is issued I shall not employ any person in any manner SPECIAL It
so as to become subject to the Workers Compensation Laws ADDRESS s qry e CONDITIONS O
CITY ZIP- V
Date Applicant Ir
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL DISTRICT ROUP TYPE FIRE PROCESSED BY
ENGINEER NO
Exempt ^� CONST / ZONE C~T
Exempt,
you should become subject to the Workers `J `V!
Compensation provisions of the Labor Code you must forth ADDRESS t j J W
with comply with such provisions or this permit shall be LL'
deemed revoked TEL STATISTICAL CLASSIFICATION APT ON N
CONTRACTOR NO Z �I '!!]1//.. Z
LICENSED CONTRACTORS DECLARATIONLIC CLASS NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO O SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC n2 V Professions Code and my license is in full force and effect CITY C IT CLASS V CIDA SQ FT NO OF NO OF CHECKBK
Lcense'Number `b1yu1 Lc Class SIZE -L3 STORIES FAMILIES ONE
VAL I N G) II o o t
Contractor 3 aL A Y V�`�_ Date �' DESCRIPTION OF WORK A D ❑ $
I am exempt under Sec JA - ✓<i �y
t ALTER ❑
B 8P C for this reason M d REPAIR ❑ $
Date USEOIF BLDG DEMOL ❑ �036 A
EXISignature APPLICANT TEL FINA # e o o e
OWNER BUILDER DECLARATION PRINT NO DATr ��`
1 hereby affirm that I am exempt from the Contractor s License I I o o! 0
Law for the following reason (Section 7031 5 Business and ADDRESS FI
Professions Code) 3.500
BUILDING 0 0 0
I as owner of the property or my employees with ADDRESS ;,f ` �+ `•` J 0 8 5 M, �2
wages as their sole compensation will do the work and J� i V
the structure is not intended or offered for sale(Section LOCALITY ® (p,8' y�
7044 Business and Professions Code) ° MOVING TEL b
1 as owner of the property am exclusively contracting CONTRACTOR NO o2� # ®3
with licensed contractors to construct the project (Sec - "�" �I - 350,00=
tion 7044 Business and Professions Code) ADDRESS - J��' '; 8.05-t88- 3500,06
REQUIRED TOTAL SETBACK �q p�d �
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH 7•, �-'a O # Q
I hereby affirm that there is a construction lending agency for FRONT � W
the performance of the work for which this permit is issued P L
(Sec 3097 Civ C ) SIDE
148525
PL 1
Lender s Name �j/) /1 LDMA Ref # - 4852506
Lender s Address P C-Fee$ V�/ V Permit Fee 0 9 1 6,-88
a I certify that 1 have read this application and state that the �-� Issuance Fee 0, -,5p LDMA P/C#
9 above information is correct I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction Total Fee 41 JC LDMA Perm #
R and hereby authorize representatives of this County to enter
$ upon the above mentioned property for inspection purposes j
aRa, UJ
( — I\ t3 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o I
Applicant or Agent Dote !