HomeMy Public PortalAbout5757 ALESSANDRO AVE_Building__ WORKERS' COMPENSATION DECLARATION
hereyto self
insure, oraffirm a certificate of Workers' Compensation that I have' a certificate ofconsent Insurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo.l 7 Z()d R 7d R 7 C"ompony _qtatA F'uOrl
Certified copy is hereby furnished. �'l:yaa FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building ins ec- BUILDING
tion department. ADDRESS 5757 Al I t-ssanrlrn
CITY Temple City ZIP 91780 .
Date q���A 1 Applicant LOCALITY
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 50X11 O NOW ON LOT 2 CROSS ST.
COMPENSATION INSURANCEASSESSOR ,L
(This section need not be completed if the permi r one TRACT BLOCK LOT NO. p MAP BOOK �p 7 PAGE fid' PARCEL O.Z-/
hundred dollars ($100) or less.) TEL. USE ZONE MAP
OWNER Don McMullin N0.818-441 /J No.
I certify that in the performance of the work for which this 5612 // SPECIAL }
permit is issued, I shall not employ any person in any manner ADDRESS 1114 Milan Ave /� CONDITIONS
so as to become subject to the Workers' Compensation Laws. O
CITY na ZIP U
Date Applicant ARCHITECT OR TEL. M
NOTICE TO APPLICANT: If, after making.this Certificate ENGINEER NO DISTRICT GROUP TYPE FIRE PROCESSED BY
cae oCONST. ZONE �
Exemption, you should become subject t the Workers' ���/ /J 3 V Z Ua
Compensation rovisions of the Labor Code, ou must forth- ADDRESS G /� LU
with comply with such provisions or this permit shall be TEL.8 0 5 STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR =Qpgt NO. Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.�DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS2 7 7 2 O Ave. SCOtt N6.619 7 6 4
(commencing with Section 7000)of Division 3 of the BusinessLIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY Valencia CLASS $ 3 VALIDATION
SQ. FT. L NO. OF NO. OF CHECK BK. PG.
License Number 619 7 6 4 Lir. Class B SIZE , STORIES 1 FAMILIES ONE
R' VALUATION
Contract 9/6/91 DESCRIPTION OF WORK NEW ❑ /�
ADD ❑ $ (!CSO ►
I am exempt under ec
EJn
ALTER Rol
B.&P.C. for this reason Prefab Fireplace REPAIR ❑ $
Date: U
EXISTING BLDG. Single Family DEMOI ❑
Signature APPLICANT TEL• FINAL
OWNER-BUILDER DECLARATION (PRINT) NO-2 9 5_
DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT BY•-
BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ;•el_-
the structure is not intended or offered for sale(Section LOCALITY , n a f/ _ ,_
7044, Business and Professions Code.) MOVING TEL. -
AR),
�L / - l
ElI, as owner of the property, am exclusively contracting CONTRACTOR NO.
�. �� 7 `�
with licensed contractors to construct the.project (Sec- ADDRESS CJ 't`tst= `�3 �_ 6"
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT' q. �A,
the performance of the work for which.this permit is,issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L. .
,Lender's Name 0010 F1 r<
0 / p # `
n
P.C. Fee$ Permit Fee (Of LDMA Ref. ;; -
� Lender's Address , -•-,,_ _ ;yFs `-;'�`.�.
0 1 certify that I have read this application and state That the Issuance Fee LDMA P/C#
8 above information is correct. 1 agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee �' LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date