HomeMy Public PortalAbout4815ALESSANDRO AVE_Building (6) W{ORKERS COMPENSATION DECLARATION
insure or a certificate of Weorke scertificate
pensat on Insuranceself APPLICATION FOR BUILDING PERMIT
+ or a certified copy thereofa 3800 Lab C ) -
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No _ Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING Ss t
ADDRESS
❑ Certified copy is filed with the county building mspec BUILDING / '
tion department 0A1,q g e 04 *4yO1 �,0,'.9 ADDRESS �T�/S- /q11-�
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Date�6 (� - Applicant .l/ moi CITY �L� C ! ZIP LOCALITY
-CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT r NOW ON LOT L-� CROSS ST
(This section need not be completed if the permit is for one TRACT BLOCK o LOT NO ASSESSOR
MAP OK 4m T GE ' PARCEL
hundred dollars ($100)or less ) i
TEL USE Z NE _ MAP
I certify that m the performance of the work for which this OWNER �"��. /tr/SS'�L ��ir `ZQ�"y/! NO
permit is issued I shall not employ any person in any manner SPECIAL,ONS
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ADDRESS I ^/O CONDIT .
so as to become subject to the Workers Compensation Laws �g Q
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afy A CITY L0 G/ ZIP { F V
Date Applicant y
NOTICE TO APPLICANT If afters making this Certificate of ARCHITECT OR TEL RS
DISTRICT GR TYPE FIRE PR SSED BY O
Exemption you should become subject to the Workers T ENGINEER NO �� CONST/i ZE U
Compensation provisions of the Labor Code you must forth ` ADDRESS 4 l ,VW
with comply with such provisions or this permit shall be D-
deemed revoked G igTYO TEL 3a� _!�� STATISTICAL CLASSIFICATION v APT C NDO , Z
ACTOR NO /n �ff
LICENSED CONTRACTORS DECLARATION IC CLASS NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Zino -S �'Y/t-"�`C Z- ��
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP t
Professions`Code and my license is in full force and effect CITY ORS p(//9
CLASS �-�I f3' BK PG VALIDATION
SQ FT NO OF NO OF CHECK
License Number, 12--ll 1-['7 Lc Classc--Z'� SIZE 2-c, STORIES FAMILIES R ONE
x,77 C ❑ VALUATION Q
Contractor_� 2- Date ��� -S� DESCRIPTION OF WORK < NEW
❑ ADD $
,
I am exempt under Sec T� ALTER ❑
B&P C for this reason REPAIR ❑ $
US F
Date EXISTING BLDG DEMOL ❑
Signature APPLICANT TEL FINA
- OWNER BUILDER DECLARATION PRINT NO DAT _ a
I hereby affirm that I am exempt from the Contractor s License "
Low for the following reason,(Section 7031 5 Business and ADDRESS FI °
Professions Code) PRESENT B
❑ I as owner of the property or my employees with BUILDINGADDRESS ;9 7 7 0,5 A
wages as their sole compensation will do the work'and
the structure is not intended or offered for sale(Section LOCALITY ® # o • o a 0 J
7044 Business and Professions Code) MOVING TEL s
❑ 1 as owner of the property am exclusively contracting '' CONTRACTOR NO • • 498 8
with licensed contractors to construct the protect (Sec ADDRESS �' t o o s 4 9 8 8 h-
tion 7044 Business and Professions Code)
REQUIRED TOTAL SETBA a O
CONSTRUCTION LENDING AGENCY SET BACK yYARD HWY . PROP LINE WIDTH Q a 9 t-8 7
1 hereby affirm that there is a construction lending agency for FRONT l
the performance of the work for which this permit is issued s. P L t
(Sec 3097 Civ C ) SIDE °
4 PL
Lender s Name
a Q LDMA Ref #
Lender s Address P C Fee$ Permit Fee �J Y
I certify that I have readLDMA loo.'this application and state that the a Issuance Fee P/C# t
above information is correct I agree to comply with all County Investigation Feed
0 ordinances and State laws relating to building construction Total ree 1 LDMA Perm # + t
and hereby authorize representatives of this County to enter , a
upon the above mentioned property for inspection purposes '
m Y � ,
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t-5-'(Z-`l SEE REVERSE FOR EXPLANATORY LANGUAGE t
Signature of Applicant or Agent', Date a
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