HomeMy Public PortalAbout5233ALESSANDRO AVE_Building WORKERS COMPENSATION DECLARATION -
hereby affirm that I have a certificateof consent to Self A P P L I CATION FOR BUILDING PERMIT
—insure-or a certificate of-Workers_Compempenstion Insurance or
a certified copy thereof (Sec 3800 Lab C ) '— COUNTY OF-LOS ANGELEk-,�, & BUILDING AND SAFETY
Policy No Company
Certified coBUILDING
py is hereby furnished ADDRESS
FOR APPLICANT TO FILL IN
Certified copy is filed with the county building inspec BUILDING
tion department ADDRESS 3 (f�3 LOCALITY
NEAREST
Date Applicant ` CITY72 ZIP 1 CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS -"-
OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT ~3 X 19711OW ON LOT MAP BOOK I PAGE PARCEL
1
(This section need not be completed if the permit is for one ` US ZONE MAP
hundred dollars ($100) or less ) r TRACT BLOCK LOT NO
TEL '\ SPECIAL l a
OWNER Se NO CONDITIONS Q
I certify that in the performance of the work for which this DISTRICT U PE FIRE POC ED BY V
permit is issued I shall not employ any person in any manner
so as to become subleci to the Workers Compensation Laws ADDRESS �j� (j NST ZONE ��
"' • CITY re (� ZIP Q ' V [�
Date Applicant STATISTICAL CLASS IC ION APT CONDO U
NOTICE TO APPLICANT If after making this Certificate of ARCHITECARCHITECT OR TELNO W
Exemption you should become subject to the Workers CLASS NO DWELL UNITS H
Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP
with comply with such provisions or this permit shall be
deemed revoked TEL VALIDATION
CONTRACTOR Q W NO BK PG
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 $ QQ
i
SQ FT NO OF NO OF CHECK
License Number Lic Class SIZE STORIES FAMILIES ONE
Contractor Date DESCRIPTION OF WORK '"
NEW
$ y J
ElI am exempt from the licensing requirements as I am a X ADD
licensed architect or a registered professional engineer ALTER FINAL
acting in my professional capacity (Section 7051 OQ42 O REPAIR DATE li II/
Business and Professions Code) USE OF _ r
TING BLDG DEMOL FINAL
By
Lic or Reg No _Date APPLICANT TEL V�-
OWNER BUILDER DECLARATION PRINT NO
I hereby affirm that I am exempt from the Contractor s License
Low,for the following reason (Section 7031 5 Business and ADDRESS _ Q 1 7 9 A
Profe ons Code) PRESENT
BUIL # 0 0 0 0 0DING
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 2 0 0 25A 0 0
7044 Business and Professions Code) - MOVING TEL
I as owner of the property am exclusively contracting CONTRACTOR NO o e o25000
3:
with licensed contractors to construct the protect (Sec ADDRESS 0 7 O 2-81
tion 7044 Business and Professions Code)
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH
I hereb/affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P L �� t
(Sec 3097 Civ C ) SIDE
PL
Lender s Name --
`�
Lender s Address P C Fee$ Permit Fee
w I certifythat I have read this application and state that the )
PP Issuance Fee
above information is correct 1 agree to comply with all County Investigation Fee
S - ordinances and State laws relating to building construction Total Fee
and hereby authorize representatives of this County to enter
aupon the above mentioned property for inspection purposes
m
d 1_ SEE REVERSE FOR EXPLANATORY LANGUAGE
a24=,-
Signature of ApR4canVXr hgent Dote
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