HomeMy Public PortalAbout6042 ALESSANDRO AVE_Building__ t T
WORKERS COMPENSATION DECLARATION
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insure hereby
oraffirm a certificate of have
orke sriificate of CompensaT onSQInsuraar self
APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company f /�
Certified copy is hereby furnishedFOR APPLICANT TO FILL IN - ADDRESS
Certified copy is filed with the county building inspec BUILDING
hon department ✓ ADDRESS �2 $S - LOCALITY
NEAREST
Date Applicant CITY C. ZIP CROSS ST / G
CERTIFICATE OF EXEMPTION FROM WORKERS / / NO OF BLDGS ASSESSOR o �j
`COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK �O PAGE PARCEL Dd
(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
TEL i SPECIAL +
I certify that in the performance of the work for which this } RAO r 67/1� NO CONDITIONS d
permit is issued I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY 0
so as to become subject to the Workers Compensation Laws ADDRESS U��s /�� CONST r- ZO
01
Date Applicon _ CITY ZIP v STATISTICAL CLASSIFICATION APT CONDO
NOTICE TO APPLIC NT If after making this Certifcat Of ARCHITECT OR TEL
Exemption you should become subject to the Workers ENGINEER CLASS NO DWELL UNITS - CL
Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP rn
with comply with such provisions or this permit shall be TEL Z
deemed revoked CONTRACTOR NO BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO #LUATION
(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 oil
r 9 8/I, (] A
SQ FT NO OF NO OF CHECK o 0 0 0
License Number Lc Class SIZE STORIES FAMILIES ONE
Contractor Date DESCRIPTION OF WORK
NEW ❑ $ � Qr 2 ° 33780
a x337
❑ I am exempt under Sec
GE ADD 80
ALTER ❑ FINAL ��,� �➢ 0 3 19-84
❑ �o
B 8P C for this reason REPAIR DATE
USE OF K DEMOL
Date EXISTING BLDG C tai ❑ FINAL
Signature APPLICANT TEL A
OWNER BUILDER DECLARATION PRINT NO
I hereby affirm that I am exempt from the Contractor s License -9� 0 4 a 6 A
Law for the following reason (Section 7031 5 Business and _&RESS , ,
Professions Code) # 0{0 0 0 0 1
BUILDING
ADDRESS 2'- 261 3 0
I as owner of the property or my employees with t
wages as their sole compensation will do the work and
LOCALITY 2'6 1 3,(�
the structure is not intended or offered for sale(Section - oto �
7044 Business and Professions Code) MOVING TEL
❑ CONTRACTOR NO
I as owner of the property am exclusively contracting 3=8'4
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code) ( Z
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 ,
the performance of the work for which this permit is issued P L
(Sec 3097 Civ C ) SIDE _
m PL
Lender s Name
PC Fee$ Permit Fee
Lender s Address
I certify that I have read this application and state that the Issuance Fee
above information is correct I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction Total Fee
d and hereby authorize representatives of this County to enter
upon t above mentions property for inspection purposes }
ti--j SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Ap cant or Agent 6ate Os