HomeMy Public PortalAbout5934, 5934 1/2 ALESSANDRO AVE_Building__ I
WORKERS' COMPENSATION DECLARATION --r
hereby affirm that I haver certificate of consent to self A P P L I CATI O N FOR B I L D I N ERM I T
insure, or a certificate of Workers' Compensation Insurance, �j
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES r �� BUILDING AND SAFETY, 934 --34 !
Policy No. Company
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING'
tion department. ADDRESS A e>SA►tid LOCALITY
NEAREST '
Date Applicant CITY ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' . OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE ARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO.
SPECIAL
/�1 �✓ V /� '
I certify that in the performance of the work for which this OWNER V CONDITIONS d// Jf DISTRICT GROUP TYPE FIRE PR SSED BY O
permit is issued, I shall not employ any person in any manner ADDRESS `L LE� 1W CONST. ZO E V
so as to become subject to the Workers'Compensation Laws.
J� Date Applicant �, ` dLe D� CITY ,� ZIP STATISTICAL CLASSIFICATION PT. CONDO' O
NOTICE Td APP (CANT: If, after makind this Certificat of ARCHITECT OR TEL.
ENGINEER NO. CLASS NO. -!9- L. UNITS LY
Exemption, you should become subject to the Workers' a
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP N
with comply with such provisions or this permit shall be ?
deemed revoked. ✓ TEL. BK. PG, VALIDATION
COMRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code, and my license is in full force and effect. CITY* CLASS 010. l� �'C'
$Q. FT. NO. OF, 'l NO. OF l CHECK 2-3
License Number Lic.Class SIZE Q STORIES T� FAMILIES Hyl ONE
Contractor Date DESCRIPTION OF WORK S NEW $ Z (9 �(��
I am exempt under Sec. d . ` 0 ADD ❑ �Y D�
- ALTER ❑ FINAL
B.BP.C. for this reason REPAIR ❑ DATE
Date: USE OF DEMOL FINAL
LDG.
EXISTING B ❑ By
Signature APPLICANT TEL.
OWNER-BUILDER DECLARATION PRINT) NO.
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): PRESENT
aBUILDING
I, as owner of the property, or my employees with 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.
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct theproject (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY YARD HWY
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
m P.L.
Lender's Name A
Lender's Address P.C. Fee$ Permit Fee
I certify that 1 have read this application and state that the + Issuance Fee Q
above information is correct. I agree to comply with all County Investigation Fee �+ I
g ordinances and State laws relating to building construction, Total Fee
and hereby authorize representatives of this County to enter
u the Qbove-men Toned property for inspection purposes.
a
1 "YSEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant r Agent D- ®3