HomeMy Public PortalAbout5754 ALESSANDRO AVE_Building__ n J JWOOERS COMPENSATION DECLARATION /
re4ry affirm that I have o certificate of consent to self APPLICATION F BUILDING PERM � �
insure or a certificate of Workers Compensation Insurance
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rtified copy thereof (,Se¢ 3800 Lab C ) f,,A,� COUNTY OF LOS ANGELES BUILDING AND SAFETYo�_Company 5�Ca�C FSJod
Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with the county building inspec BUILDING ] Pic
tion department 1f/J1 ADDRESS 5 �^ �Yl C�IZO
Date /� Applicant 1 CITY ( �yh P Le- �t�� ZIP 61 1 v LOCALITY
CERTIFICATECOMPENSATION IINSURANCEPTION FROM ORKERS SIZE OF LOT OX ( 1 NOW ON LOT7 NO OF S L CROSS SST
(This section need not be completed if the permit is for one ) „�^7 ASSESSOR a
hundred dollars ($100)or less ) TRACT l� BLOCK LOT NO /sU MAP BOOK PAGE PARCEL
USE Z MAP
I certify that in the performance of the work for which this OWNER R � ' NO
permit
NO '
permit is issued I shall not employ any person in any mannerADDRESS 5 ! �SS�j-Y�d�►ZC� /1 �I SPECIAL
so as to become subject to the Workers Compensation Laws lZv CONDITIONS
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Date Applicant CITY (q ZIP / /O w
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption you should become subject to the Workers ENGINEER NO �,/ k(fes CONST`/ ZONE U
Compensation provisions of the Labor Code you must forth ADDRESS r yQ( /S/ j W
with comply with such provisions or this permit shall be
deemed revoked �^ p TEL I STATISTICAL CLASS ICITION APT NDO N
CONTRACTOR 806 6 L 1 U6I-) NO U Z- Z
LICENSED CONTRACTORS DECLARATION LIC CLA55 NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 73 f�,/�b LFeu Sr NO �
(commencing with Section 7000)of Division 3 of the Business and /j// 3 LIC SEWER MAP
Professions Code and my license is in full force and effect CITY QA (t CLASS —� BK PG VALIDATION
4 SQ FT NO OF NO OF ) CHECK
License
IN v , Lic Class SIU STORIES FAMILIES ( ONE
/ r VALUATION
Contractopots
/ �} DESCRIPTION OF WORK Cl - IV ( NEW ❑
r ® s / 51_.s t
ADD 4
❑ I am exempt under Sec ALTER ;2863, 1 A
LSA ❑
B 8P C for this reason �Q � — REPAIR $ # o e e e o ,1
Date USE EXISTING BLDGt �►'-s ✓P ' tDEMOL ❑ - 153.00
Signature APPLICANT TEO I FINAL
OWNER BUILDER DECLARATION PRINT /O U �� NST' ✓Q�"Zf�� DAT ���0
j hereby affirm that I am exempt from the Contractor s License ADDRESS �7 '.�y� en 9�J� ° ° 15300'
Law for the following reason (Section 7031 5 Business and S FI
Professions Code) IMENT _
❑ I as owner of the property or my employees with ADDRE55M122l o 1218-87
wages as their sole compensation will do the work and rw
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code) MOVING Y T Y
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I as owner of the property am exclusively contracting CONTRACTOR n `
with licensed contractors to construct the project (Sec FInvestiga
2 `
hon 7044 Business and Professions Code)
TOTAL SETBACK CONSTRUCTION LENDING AGENCY YARD HWY PROP LINE WIDTH
I hereby affirm that there is a construction lending agency for t F +
r
the performance of the work for which this permit is issued -
(Sec 3097 Civ C ) t
+
Lender s Name
c
m ` LDMA Ref N °
Lender s Address $ Permit Fee G y
a I certify that I have read this application and state that the t
d S
Issuance Fee i LDMA P/C M
o above information is correct I ogres to comply with all County ee
0 ordinances and State jaws relating to building construction r
R and hereby-authorize representatives of this County to enter Total Fee LDMA perm H _
upon thea ave mentioned operty for inspection purposes n tYb
m
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or gent Date
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