HomeMy Public PortalAbout5233ALESSANDRO AVE_Building (5) t
w_,_or,.-,C,
RKERS COMPENSATION DEILARATION
m that I have a certificate of consent to self APPLICATION 'FOR BUILDING P E RM I T
rtificate of Workers Compensation Insurance
P. , or rticopy thereof (Sec 3800 Lab C ) r r�
Policy N S11�-Company \ t COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished BUILDING
❑ 5 FOR APPLICANT TO FILL IN - - ADDRESS _Z
Certified copy is filed with the county building inspec BUILDING
do dep rtment 0. ADDRESS LOCALITY (�[
r -s/' NEAREST
Date 2 Applicant4�& CITY - �` 7 ZIP CROSS ST
CER IFICATE OF EXEMPTI FROM WORKERS NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the perm is for one /� f'7 USE ZONE MAP
hundred dollars ($100)or less ) TRACTC,+ C 5 � BLOCK LOT NO /^ NO
TEL .` `- I - SPECIAL
I certify that in the performance of the work for which this OWNER , - S( NO 3`t13� C CONDITIONS 13-
permit is issued I shall not employ any person in any manner u'r DISTRICT GROUP TYPE FIRE PROCESSED BY
sof to become subject to the Workers Compensation Laws ADDRESS 52-3 /v r�L�r n CONST ZONE
Date Applica 1`S L CITY �(�7 ZIP STATISTICAL CLASSIFICATION APT CONDO - 0
ARCHITECT OR L
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO � tVti
Exemption you should become subject to the Workers CLASS NO DWELL UNITS LU
Compensation provisions of the Labor Code-you must forth ADDRESS - - SEWER MAP
with comply with such provisions or this permit shall be
deemed revoked CONTRACTOR TEL
BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION ,
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS I C4'a46"-"RO 5��O I 1 ALUATION
(commencing with Section 7000)of Division 3 of the Business and LICt
Professions Code and my license is in full force and effect CITY L'2611 �bpx CLASS xI.OD6
00
000.License Number 35�Io � Lic Class
SIZE FT SIZE MILNO OF NO LIIES CHECK
EK
to cu/ NEW $
Contractor 7 Kf(i�'c i Date DESCRIPTION OF WORK "t fl P
X❑ I am exempt under Sec �e D E]
)TER ❑ FINAL
B&P C for this reasonREPAIR ❑ DATE �O-
USE OF C
Date EXISTING BLDG e �/L DEMOL E] B NAL� J
Signature
APPLICANT L Y
OWNER BUILDER DECLARATION (PRINT)
I hereby affirm that I am exempt from the Contractor s License �Q 7—C,
Z/�]Law for the following reason (Section 7031 5 Business and ADDRESS _ r 9 2 2 8 A
Professions Code) PRESENT +
�� # 0 0 0 0 0 1
❑ BUILDING _
I as owner of the property or my employees with ADDRESS-
wages
DDRESSwages as their sole compensation will do the work and LOCALITY 2 0 0 4 0 5 a
the structure is not intended or offered for sale(Section _ _
7044 Business and Professions Code) MOVING TEL o o o 4 0 5 0 U
TOR NORAC
I as owner of the property am exclusively contracting CONT0 228-84
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code)
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINf WIDTH t,
I hereby affirm that there is a construction lending agency for FRONT 4
the performance of the work for which this permit is issued P L
(Sec 3097 Civ C ) SIDE
FD PL
Lender s Name
PC Fee$ Permit Fee �Y
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 LL
ordinances and State laws relating to building construction Total Fee Otr 7
l� and hereby authorize representatives of this County to enter
upon t e above mentioned roperty for inspection purp ses -
o " �5 SEE REVERSE FOR EXPLANATORY LANGUAGE
n
ignature of Appli t or Agent Date If ®_