HomeMy Public PortalAbout5926 ALESSANDRO AVE_Building__ � � � Q-f
WORKERS' COMPENSATION DECLARATION rl.� : IQ S p t�i 7 (�
Ihereby oracertif ca
affirm
that
te of Workers' Compensation consent
Insuran Insurance, APPLICATION FOR BUILDING P E RM I T
or a certified copy thereof (Sec. 3800, Lob. C.) / COUNTY OF LOS ANGELES BUILDING. AND SAFETY
Policy No�Company rr�o"o �zlGFtv"�Atfy
BUILDING
Eel Ce ifi copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 7.2,b
Certified copy is filed with the county building inspec- BUILDING i
tion department. ADDRESS
/ 2 G
Date Applicant rrGu. CITY 7C_r.- C4 ZIP q17 go LOCALITY
16ERT'IfICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. �/ NEAREST
COMPENSATION INSURANCE SIZE OF LOT G Ya NOW ON�LOT CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
OWNER I Co NO. �(2Y� OYG USE Z E MAP G
I certify that*in the performance of the work for which this c NO.
permit is issued, I shall not employ any person in any manner ADDRESS �C/C3 /�� SPECIALi
so as to become subject to the Workers'Compensation Laws. � � RJ CONDITIONS 0
e' /�+. rc w� (p w c'. ��✓• CITY ZIP d V
Date �y Applicant Zr ARCHITECT OR TEL.
NOT, T APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT G UP TYPE FIRE PRO SED BY O
Exemption, you should become subject to the Workers' CONST. Z NE U
Compensation provisions of the Labor Code, you must forth- ADDRESS 5(
with comply with such provisions or this permit shall be D.
deemed revoked. ' TEL. STATISTICAL CLASSIFICA ION APT.CONTRACTOR rwrca �a�. S�-- NO. 6Z 672116(ONDO.
Z
LICENSED CONTRACTORS DECLARATION ��// LIC CLASS NO. DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS z/d AeW V /07 4 NO. 4126 ,f'5/k
(commencing with Section 7000)of Division 3 of the Business and ,{ LIC. el� SEWER MAP
Professions Code, and my license is in full force and effect. CITY /� wtr CLASS — VALIDATION
U SQ. FT. NO.OF NO. OF CHECK BK. 2- S,(j
License Number T n� lr57 7r 2 `' Lic.Class �� SIZE STORIES ' FAMILIES ONE
/� ��++ c - � VALUATION
Contractor A—,-O roti BOAC_ Date °g DESCRIPTION OF WORK rti.0 /!'r I O •► NEW
$
ADD
I am exempt under Sec. d C 4 ALTER
B.&P.C. for this reason REPAIR $ # 0 0 o jo.o.1
Date: USE OF
EXISTING BLDG. DE nil
Signature APPLICANT - TEL.
g FINAL I o o 6 Q 5 OOWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License �v P o 0060.502:
Law for the following reason (Section 7031.5, Business and ADDRESS C( A� da., FI �
Professions Code): R B
I, as owner of the property, or my employees with ADDRESS Q 0 4 8
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.
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK F
SET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
1 LDMA Ref. #
� .J
Lender's Address P.C. Fee$ Permit Fee
I certify that I have read this application and state that the Issuance Fee GViS LDMA P/C#
o above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee a LD"Perm. #
H and hereby authorize representatives of this County to enter ry �-
upo a above`mentio roperty for inspection purposes. C.�R��f (Q,j'� /t •��Oc�r V
� !`S/ SEE REVERSE FOR EXPLANATO ANGUAGE ,Ma4i
Signature of Applicant or Agent 1, in-te
1 � .S A1,W,1_0M-17 �.