HomeMy Public PortalAbout5546 ALESSANDRO AVE_Building__ WORKERS COMPENSATIOt KT.AfA-TION r ', 7 ,C
hereby affirm that I have a certificate a of consent to see: APPLICATION FOR BUILDING PERMIT
insure of a certificate of Workers Compensation ionInsurance �
or a certified copy thereof (Sec 3800 Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnishedFILL IN- ADDRESS BUILDING
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❑ Certified copy is filed with the county building inspec BUILDING FOR APPLICANT TO
tion department + ADDRESS //JJ��$ V/l�i0/LC7 LOCALITY
NEAREST
Dote Applicant CITY / 6 7 ZIP 1 0 CROSS ST UL
CERTIFICATE OF EXEMPTION FROM WORKERS VNO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT 13,2-w 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 t NO 2 0
TEL / �j c ,�, SPECIAL
1 certify that in the performance of the ork for which this OWNER /L I LL NO �l0—d(o� CONDITIONS d
permit is issued I shall not employ any p rson i any m ner DISTRICT GROUP TYPE FIRE PROCESSEDBY O
so as to become subject to the Workers o sate L ADDRESS 5^ 4eSS 0", �" CONST ZONE V
ate Applicant Al CITY _ ZIP ?✓yam STATISTICAL CLASSIFICATION APT CONDO O
ARCHITECT OR T
NOTICE TO APPLICANT If afte making this Certificate of ENGINEER O V
Exemption you should become subject to the Workers CLASS NO DWELL UNITS W
Compensation provisions of the Labor Code you must forth V�1
ADDRESS SEWER MAP
with comply with such provisions or this permit shall be .?
deemed revoked CONTRACTOR Np , BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code and my license is in full force and effect CITY CLASS $ ,
SQ FT NO OF NO OF CHECK
License Number Lic Class SIZE �3� STORIES FAMILIES / ONE
' b
Contractor Date DESCRIPTION OF WORK NEW i
❑
- ADD
I am exempt under Sec e
B 8P C for this reason ALTER ❑ FINAL
REPAIR ❑ DATE
USE OF
Date EXISTING BLDG DEMOL ❑ BY
NA
Signature
APPLICANT T
OWNER BUILDER DECLARATION PRINT /7� L NOEL VG'6?,6T� `
I hereby affirm that I am exempt from the Contractor s License ADDRESS !�(t� gOv=
Law for the following reason (Section 7031 5 Business and -
Professions Code) FIRES NTr
ElBUILDING
I as owner of the property or my employees with ADDRESS 911 1 2 A
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code) MOVING TEL # CIO 0 0 0 1
ElI as owner of the property am exclusively contracting CONTRACTOR NO - - 0 1 0 T3with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM EXIST 0 0 10613'
SET BACK PROP LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT0 222-84
the performance of the work for which this permit is issued PL !�;L0 O -��
11011.
(Sec 3097 Civ C ) SIDE
FD PL
I Lender s Name /
Lender s Address 2
$ PC Fee$ r Permit Fee y r (j J
—
I certify that I have read this application and state that the Issuance Fee .S U
above information is correct I agree to comply with all County Investigation Fee
ordinance and State laws relating to building construction Total Fae
Y1 and here authorize repres ntat ves of this County to enter q
upon th above men one ro r for inspection purposes
6 SEE REVERSE FOR EXPLANATORY LANGUAGE -
Sig re of Applicant or Agent Date ®s