HomeMy Public PortalAbout5750 ALESSANDRO AVE_Building__ WORKERS' COMPENSATION DECLARATION
he y affirm that I have r certificate of"consent to self _ APPLICATION �F O R. BUILDING PERMIT
insure, or,a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800; Lab. C.)
y�/� 5 J. �. COLINTY-OF L•OS ANGELES ' BUILDING AND SAFETY--
Polyay No& Company
BUILDING
Certified copy is hereby furnished. " FOR APPLICANT TO FILL IN- ADDRESS Gc�•G / LCC/-�?
Certified copy is filed with the county building inspec- BUILDING-ADDRESS 7 e Yp
tion department. ? /� ` � 7►
CITY/'��'�t / Cwt, zip 91700 LOCALITY
ate Applicant NO. OF BLDGS.
NEAREST-
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT SC> I p S NOW ON LOT - -
CROSS ST..
COMPENSATION INSURANCE ASSESSOR
I (This section need not be completed if the permit is for one TRACT BLOCK I LOT NO. MAP BOOK Q J D PAGE 08� PARCEL V�
hundred dollars ($100) or less.) TEL.
OWNER G p NO - - USE.ZONE ._.MAP `�z
.. I certify that in the performance of the work for which this SPE /
I permit is issued, I shall not employ any person in any manner ADDRESS-157 -So ' S5CtAr,0 _ - - r i CONDITIONS O
so as to become subject to the Workers' Compensation Laws. 'ry`.�-� l / �`// __ 0
CITY• e,^q ! L ZIP` D'�
Date Applicant ARCHITECT O TEL. DISTRICT- GROUP TYPE -FIRE PROCESSED BY tY
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO.
CONST. ZONE U
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS '��� � Irk N
with comply with such provisions or.this permit shall be TELZ STATISTICAL CLASSIFICATION _ APT. - CONDO. Z
deemed revoked. CONTRACTOR Je Y �1 lJ t NO. 6� -
LICENSED CONTRACTORS DECLARATIONLIC• 941/0,3
1 CLASS NO. J DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS tiX 3 6 Z NO -
I 3 !� SEWER MAP
(commencing with Section 7000)_of Division 3 of the Business C / P LIC.
and Professions Code,and my license is in full force and effect. CITY .S �D trJ't� CLASS G Z BK. Lam'PG. VALIDATION
�1 SQ. FT. cit1 NO. OF NO. OF CHECK
�(
License Number / T/03 � Lic. Class G� SIZE �o T STORIES FAMILIES ONE
T l - - VALUATION
ContractorGNC�/��/ -Y�13W Date �� DESCRIPTION OF WORKId NEW d-Pa
1 ADD
F1I am exempt under Sec. 1 A CA Pe poll.__ _., _
ALTER Y
B.&P.C. for this reason REPAIR ❑ a
Date: USE OF....- / - DEMOL ❑p
EXISTING BLDG. 6-c,,Y'ci
Signature /y( i� APPLICANT ,�^ /_ r _ TEL. - FINAL
NER-BUILDER'DECLAR fON _(PRINT) /'1 �y r i 0 NO. _160
!� / DATE_.
I hereby affirm that l am exempt from the Contractor's License �- 0 3-b Z k7 4 Dvr�C.
Law for The following reason (Section 7031.5, Business and ADDRESS FINAL• _
Professions Code): PRESENT _. _ ._ --._ .__ ._ _ _. . :-By--
BU
Y- a
BUILDING + aY
❑ I, as owner of the property, or my employees with ADDRESS - -
wages as their sole compensation,will do the work and - "ice' '
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING - - -- TEL.-
CONTRACTOR NO. _
❑ I, as owner of theproperty, am exclusive) contracting
Y 9 .,1 �• �t` �a-t 92,
with licensed contractors to construct the project (Sec- fi ' r 3
tion 7044, Business and Professions Code. ADDRESS
-REQUIRED- TOTAL-SETBACK FROM - -EXIST - t ~
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH -•
I hereby affirm that there is a construction lending agency for FRONT ` ��_ 'j_T_ t_L
the performance of the work for which this permit is issued P.0 ---
(Sec. 3097, Civ. C.). SIDE
_. .._
/1/'0 A e 5 . 1_-D E 1 =
Lender's Name. --LDMA Ref. # -* -• -• -`-- -- -- - °
P.C. Fee$ Permit Fee _.
Lender's Address
I 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 /� / U LDMA Perm. # -
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
SEE_REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date -