HomeMy Public PortalAbout5720 ALESSANDRO AVE_Building__ :KERS' COMPENSATION DECLARATION
I hereu/ affirm nal I have u._'-riifi"1%e of consent to self
insure, or a certificate.of Work,s' 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 ADDRESSS ZC7 to 4L)Rcc_ /31-11JO
❑ Certified copy is filed with the county building inspec- BUILDING 2G �tflLlti'�FjOR�
tion department. ADDRESS
CITY ���� ZIP LOCALITY
Date Applicant ( NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT X gS NOW ON LOT CROSS ST.
COMPENSATION INSURANCE f ASSESSOR
(This section need not be completed if the permit is for one TRACT 6 5.O BLOCK LOT NO. MAP BOOK Z PAGE�* PARCEL
hundred dollars ($100)or less.) / /!'w TEL.[/ e��/ USE ONE MAP
OWNER C� i�Ab NO'g -vac TTNE
l Z (0
1 certify that in the performance of the work for which this AVEL ~ SPECIAL a
permit is issued, I shall not employ any person in any manner ADDRESS G[( i►ry A • S'ol F Q CONDITIONS O
so as to become subject to the Workers'C sation Laws. /�Q 0
_ u ITY ti 13 L} zip
X-COTICIE
Applicant ARCHITECT OR f' TEL.D DISTRICT GROUP. TYPE FIRE CESSED BY O
TO APP ANT: If, after mak g is Certificate of ENGINEER evt CS v�/O N04��- CONST. ./ ZONE U
Exemption, you should become subject to the Workers' �d� n( 3 1' �/- w
Compensation provisions of the Labor Code, you must forth- ADDRESS _ C• L/7& e14- v� L�� N
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. —
LIC. CLASS NO. DWELL. UNITS
LICENSED CONTRACTORS DECLARATION ADDRESS NO.
I hereby affirm that I am licensed under provisions of Chapter 9 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. CIN CLASS BK.-/-- PG.13-3 VALIDATION
SQ. FT. 1 NO. OF NO. OF / CHECK
License Number Lic. Class SIZE / STORIES FAMILIES / ONE
VALUATION
Contractor Date DESCRIPTION OF WORK j�OUb��T/a NEW
D ; �4 f
EJI am exempt under Sec. t- d /� To cyl N ��711 ,
ALTER ❑ �`
B.BP.C. for this reason Su i�F STac ffrJ REPAIR ❑ $
USE OF ��
,�
Date: EXISTING BLDG. `,I�� /A-�. DEMOL ❑
Signature APPLICANT /,,� TEL / /1
(PRINT) AW C..f74D NO FINAL l(�
OWNER-BUILDER DECLARATION to DATE "
I hereby affirm that I am exempt from the Contractor's License ADDRESS ti/' /`C. 17ny�'�A• FINAL
Law for the following reason (Section 7031.5, Business andlh�
.Professions Code): PRESENT ( BY ►
a- LS
I, as owner of the property, or my employees with BUILDING o
ADDRESS
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. ► 3W7 63.10
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. i
with licensed contractors to construct the project (Sec- ADDRESS 1 -
tion 7044, Business and Professions Code.). C i
REQUIRED TOTAL SETBACK FROM d ACCT.&
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE
I hereby affirm that there is a construction lending agency for FRONT b40. Cf
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE 2 ITEMS
P.L. TOTAL 703► 60
Lender's Name LDMA Ref. # �/� �� ,1P.C. Fee$ �' �/ Permit FeeOEiK 12�6VLender's Address f O r wjI certify that I have read this application and state that the � Issuance Fee LDMA P/C# � ) )
above information is correct. I agree to comply with all County Investigation Fee >
} ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
= and hereby autho�re' entatives o this County to enter
0000-OOQ1 7/24/
3 upon the ove- ro rty f t spection purposes. t W i
o� SEE REVERSE FOR EXPLANATORY LANGUAGE T9J7 l AM11�
Signatu of Applicant or Agent Date