HomeMy Public PortalAbout6052 ALESSANDRO AVE_Building__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION F O R BUILDING PERMIT
or a certified copy thereof (Sec.3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN
ADDRESS
13 Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS 6052 Alessandro* Avenue
Date Applicant CITY Temple City ZIP 91780 LOCALITY OM
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF SIZE OF LOT SO t X 131 NOW ON LOTS 1 NEARESST. ,
COMPENSATION INSURANCECROSS
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR
hundred dollars ($100)or less.) MAP BOOK PAGE �� PARCEL
TEL. USE WE MAP
I certify that in the performance of the work for which this NO.OWNER Jean Moore No. 287-241
permit is issued, I shall not employ any person in any manner SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS 6052 Alessandro Avenue CONDITIONS O
CITY Temple City ZIP 91780 U
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PRO $ ED BY O
Exemption, you should become subject to the 'Workers' ENGINEER NO. CONST. ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS �/•�/� R� _5 lil
with comply with such provisions or this permit shall be TEL
deemed revoked. STATISTICAL CLASSIFIC TION APT. CON N
CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATION v LIC, CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS BK /_ PG 1s'7 VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic.Class SIZE 1800 STORIES 1 FAMILIES 1 ONE
VALUATION
DESCRIPTION OF WORK NEW ❑ $ �j`1
Contractor Date ❑ V
00
ADD
I am exempt under Sec. Composition roof. ALTER ❑
B.BP.C. for this reason REPAIR $
Date: USE OF Residence DEMOL ❑ ;2'7 8 Ll A
EXISTING BLDG.
01
Signature APPLICANT TEL. FINAL # a o o s
OWNER-BUILDER DECLARATION PRINT Jean Moore NO. 287-2419 �z I .0, 4 9 8
DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS 6052 Alessandro, Temple C it FI L 'o,o 049,885o
Law for the following reason (Section 7031.5, Business and
Professions Code): p 9, 01 8'7
rVI BUILDING
jai 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 the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CK FROM EXIST.
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP.LIINE 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
m
LDMA Ref. N
P.C. Fee$ Permit Fee
Lender's Address �l
I certify that I have read this application and state that the Issuance Fee V LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee LDMA Perm. q
0 and hereby authorize representatives of this County to enter
m upon the above-mentioned property for inspection purposes.
M
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date