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HomeMy Public PortalAbout5233ALESSANDRO AVE_Building (2) WORKERS COMPENSATION DECLA)'ATION hereby affirm that I have a certificate of consent toself A P P L I`CAT 16 N FOR BUILDING PERMIT insure or a certificate of Workers Compenstion Insurance or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY a Policy No Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is filed with the county building inspec BUILDING sz tion department ADDRESS LOCALITY ¢ NEAREST Date Applicant CITY ZIP CROSS ST ` CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSOR COMPENSATION INSURANCE / SIZE OF LOT NOW ON LOT MAP BOOK I PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE EMAPTRACT BLOCK LOT NO >2Dhundred dollars ($100)or less ) TEL ,f`' EL 1 certify that in the performance of the work for which thisOWNER NO NS O permit is issued AI,sholl not employ ny person in any manner DISTRICT GROUP fPES. FIRE PROCESSED.BY U so as to become sublect to the WJQD;Z�Laws ADDRESS NT ZONE, ON o Date ,` Applicant CITY ZIP O STATISTICAL CLASSIFICATION A - CONDO U NOTICE TO A PLICANT If after making this Certificate of ARCHITECT OR TEL W ENGINEER NO CLASS NO DWELL UNITS d Exemption you should become subject to the Workers y Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP z -with'comply with such provisions or this permit shall be deemed revoked CONTRACTOR TEL BK �PG 7 VALIDATION 1 ` LICENSED CONTRACTORS DECLARATION C I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O T VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC ` -f-- Professions'Code and my license is in full force and effect CITY aj, CLASS l $ SQ FT NO OF NO OF CHECK License Number kA Lic Class _ SIZE STORIES FAMILIES ONE n 1 J NEW $ ContractorM IiZ L t�Date 2 L DESCRIPTION OF WORK I am exempt from the licensing requirem is as I am a ADD licensed architect or a registered professional engineer ALTER FINAL + acting in my professional capacity (Section 7051 REPAIR DATE Business and Professions Code) USE OF EXISTING BLDG DE MOL FINAL ( By �-LJ�- Lic or Reg No _Date APPLICANT TEL SqtJ 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) PRESENTING /\) I as owner of the property or my employees with BU SS wages as their sole compensation will do the work and 1 f the structure is not intended or offered for sale(Section kADDRE 2 0 5 7 3 A 7044 Business and Professions Code) TEL r I as owner of the property am exclusively contracting TOR NO ' # o 0 0 0 0 1 with licensed contractors to construct the project (Sec tion 7044 Business and Professions Code) 2 ° 2 3 2 0 0 D TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY K YARD HWY PROP LINE WIDTH I hereby affirm that there is a construction lending agency for f 0,-, 23200'u the performance of the work for which this permit is issued(sec 3097 Civ C ) 0,7 3 0=81 Lender s Name Lender s Address Permit Fee �p S—, a w I certify that I have read this application and state that the Issuance Fee aabove information is correct I agree to comply with all County Investigation Fee 2 . $ ordm es a State laws relating to building construction Total Fee 3d2, and by au �rizKpresentcrtives of this County to enter < upoted property for insW ses a SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Applicant or Agent ©s V