HomeMy Public PortalAbout4815ALESSANDRO AVE_Building (7) WORKERS COMPENSATION DECLARATION co
hereby affirm that I have a certificate of consent to self A P P L I C AT 1�N FOR BUILDING PERMIT JI��
insure or a certificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lab C ) t
r I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company �`
Certified copy is hereby furnished /
BUILDING
Certified copy is filed with the county building inspec t BUILDING FOR APPLICANT TO FILL IN ADDRESS J �p
hon department ADDRESS LOCALITY
Date NEAREST
Applicant�L7'� CITY CROSS ST
CERTIFICATE OF EXEMPTION 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 permit is for one USE ZONE MAP
hundred dollars ($100)or less ) TRACT BLOCK LOT NO NO
TEL - �/ SPECIAL >-
IL
I certify that in the performance of the work for which this OWNER N / CONDITIONS 0
permit is issued I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PR SSED BY O
ADDRESS — � CONST ZONE U
so as to become subject to the Workers Compensation Laws �Q f '� 50 a
Date !112,1 Applicant /{[ ( CITY >!-/ ZIP STATISTICAL LASSIFICA ION J PT CONDO O
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL
ENGINEER NO CLASS NO DWELL UNITS W
Exemption you should become subject to the Workers M
Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP CA
with comply with such provisions or this permit shall be / Z
deemed revoked CONTRALTO N046 it BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION UC
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO 7 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 lA l CLAS $ ►
� �� i
LSQ FT NO OF ^ NO OF CHECK
License Numbeerr c Class SIZE STORIES FAMILIES ONE
Contractor_�`V% �ZkMb Dote DESCRIPTION OF WORK NEW ❑ $ 2,6,�00
C e 1 3 9 6 A
❑ I am exempt under Sec ADD ❑
p ��� ALTER ❑ FINAL # o e o 0 2 3
i
B 8P C for this reason REPAIR ❑ DATE ( 2 ro 1 7 6 9 1
USE OF FINAL
_ EXISTING BLDG DEMOL ❑ BY 6:®I to e 1 7691
j
Signature .—s APPLICANT TEL �{ 2 2—8
OWNER BUILDER ECLARATION PRINT NO 3
1 hereby affirm that I am exempt from the Contractor s License 2 2 1 6 3 A
Law for the following reason (Section 7031 5 Business and ADDRESS !6J I
Professions Code) PRESENT # o o'o o 2 3
❑ of the property or my employees with BUILDING '
th ADDRESS 1
I as owner ° - 3984
wages as their sole compensation will do the work and 21
the structure is not intended or offered for sale(Section LOCALITY aro 0 3 9 8 4�
7044 Business and Professions Code) MOVING TEL
CONTRACTOR NO
1 as owner of the property am exclusively contracting 0 2 3—83
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code) 1"la 4 A
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM EXIST r
SET BACK PROP LINE WIDTH i
I hereby affirm that there Is a construction lending agency for FRONT ► # 0 0 0 0 0 1
the performance of the work for which this permit is Issued P L
(sec 3097 Civ C ) SIDE 9 2 - 26550
PL
Lender s Name t o to
2 6 5 5 Q cz
Lender s Address
PC Fee S Permit Fee O� 0 2 3—8 3
I certify that I have read this application and state that the Issuance Fee Vis (i
above information Is correct I agree to comply with all CountyInvestigatio ee
Ot
ordinances and State jaws ng to building construction
and herebuthonze rep sent fives of this County to enter Total Fee
upon t ov enti d pr erty for inspection pthrposes r NGUA��
SEE REVERSE FOR EXPLANATORY TGE
n
Signature of Applicant or Agent Date ®s