HomeMy Public PortalAbout5233ALESSANDRO AVE_Building (7) iWORKERS COMPNSATION DECLARATION
II v c►insure boraafcertif cairm rte of Workers rtCompensat oificate of consent lnsuran ell APPLICATION FOR BUILDING -PERMIT
or a certified copv thereof (Sec 3800 Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company ' a
' BUILDING
Certified
j/Q
Cer ified copy Is hereby furnished � FOR APPLICANT TO FILL IN ADDRESS J � 3 p►.7��
❑ Certified copy is filed with the county building inspec BUILDING \
tion department I ADDRESS {�1
C � n
Date Applicant CIT {.. ZIP 6 U LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS ' O OF BLDGS NEAREST A
' COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST
(This section need,not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less ) TRACT BLOCK - LOT NO MAP BOOK PAGE PARCEL
TEL USE ZONE MAP
I certify that in the performance of the work for which this OWNS NO
NO
permit is issued I shall not employ any person in any manner Com']3 � �, SPECIAL
RESS `7 l
so as to become subject to the Workers Compensation Laws ADDCONDITIONS 0 -
Date
-
Date Applicant CITY ZIP
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY O
1� DM-ENGINEER NO + CONST ZONE U
Exemption you should become subject to the Workers /�a
Compensation provisions of the Labor Code you must forth ADDRESS silt/ S W
with comply with such provisions or this permit-shall be - TEL STATISTICAL CLAS FI TION APT CONDO N
deemed revoked CONTRACTOR+ t T- W�1 NO 3� Z
D
LICENSED CONTRACTORS DECLARATION �e� ?" CLA55 NO DWELL UNITS
NO
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS `J O'� y$ SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and UC (�
Professions Code and my license is in full force and effect CITY CLASS IJ — ' BK PG VALIDATION
_ SO FT NO OF / NO OF CHECK
License NumberQEAQ_Lic Class_ SIZE STORIES 1 FAMILIES ' ONE
1 44 , VALUATION
DESCRIPTION OF WORK �i NEW ❑
+1 Contractor Date ` ADD $
7.17
,
❑ I am exempt under Sec L ❑
ALTER
B 8P C for this r son REPAIR ❑ :
Dat USE OF DEMOL ❑
EXISTING BLDG
Signature APPLICANT TEL FINAL _
OWNER BUILDE D CLARATION
(PRINT)
RINT *� \ NO DATE r ;2O 8 3, 8,A
I hereby affirm that I am exem t f m the Contract icense ADDRESS `��.0 �3
Law for the following reason ction 7031 5 Business and �y FIN # o 0,0 o e
Professions Code) PRESENT ` By
❑ BUILDING 5a3 3 � t I - 1 21L 8 8
I I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and / � f ' o e 1 24,885
the structure is not Intended or offered for sale(Section LOCALITY ��'1'^- q , J
7044 Business and Professions Code) MOVING r-- TEL `
❑ CONTRACTOR I WiJU NO O�3 C 05—, 88
I as owner of the property am exclusively contracting +
with licensed contractors to construct the project (Sec
hon 7044 Business and Professions Code) ADDRESS6-D-9-7
v�►`��' , l � �` 5 1
REQUIRED TOTAL SETBAC
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH t 4 t
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit i., issued P L
(Sec 3097 Civ C ) tInvestigotion
t
Lender s Name LDMA Ref,11
ryPermit Fee t v�
Lender s Address
1 certify that I have read this application and state that the Issuance Fee kDO P/C#
o above information is correct I agree to comply with all County ee
oordinances a State laws relating to building construction Total Fee . LDMA Permq
R and hereby thorize repress ives of th County to enter - +
upon thea ve entioned rap y for spection purposes
�6 SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Aplic t or Agent Dote