HomeMy Public PortalAbout4821ALESSANDRO AVE_Building (2) WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION' FOR B U I L Dl N G PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified.copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING - w
• ADDRESS
Certified copy'is filed with the county building inspec- BUILDING
'tion deportment. ����(�y�� ) ADDRESS
Date.% -a •Applicant ti`s ."�_ CITY L' ZIP LOCALITY
'CERTIFICATE OF EXEMPTION FROM W• KERS' NO.•OF BLDGS. - NEAREST
'COMPENSATION INSURANCEV ' 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.2 _�J I�!_ U ZO E MAP n
I certify that in the, performance of the work for which this OWNER S� NO.G Dom) I w NO.
permit is issued,T shall not employ any.pe�son in any manner ADDRESS ��, �I' SPECIAL IL,
so as to become subject to the Workers''Compensation Caws. CONDITIONS r r
14 V
Date Applicant CITY Ile- ZIP =
NOTICE TO APPLICANT: If, after making this Certificate of
ARCHITECT O TEL. DISTRICT GROUP TYPE •: FIRE PROCE SED 8Y
Exemption, you should become subject to the Workers' ENGINEER NO. r� r� CONST,'/ ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS — J ��J l� CL
W
with comply with such provisions or.this permit shall be - -
deemed revoked. TEL. c� a STATISTICAL CLASSIFI ATION APT. NDO.' Z
CONTRACTORTw Cool t ) NO.Zc65_%110 _
LICENSED CONTRACTORS DECLARATION /� LIC•��ct' {� CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed,under provisions of Chapter 9 ADDRESS l�Q51 S•SQ h 60 6) NOVfS�tJ�
(commencing with Section,7000)of Division 3 of the Business and LIC. nn a SEWER MAP
Professions Code, and my license is in full force and effect. CITY n Si10 CLASS l'-� ( BK PG "'VALIDATION
3� (J� SQ. FT: NO: OF FA OF _ CHECK
License Number c.Class SIZE STORI FAMILIES ONE
_ ♦f�� l� VALUATION
Contractory"t- (�n ""1 DatC �� ���- DEttS��CRIPTION OF WORK• C`C.b }.� ADD ❑ 5 2,305, 00
❑ I am exempt under Sec. L-L,D* Sh1Y, t J'
t ALTER
B.&P.C. for this reason _ _ v REPAIR ❑ -;
_- Date: ry USE OF E DEMOL ❑ 2 17.6 A
EXISTING BLDG. -- �
Signature APPLICANT TEL. FINAL t
O_ WNER-BUILDER DECLARATION (PRINT) NO. DATE` ' # ° ° ° ° °
hereby affirm that I am exempt from the Contractor's License
Law for the following reason.(Section 7031.5, Business and ADDRESS FINAV . ° - 59.25
Professions'Code): PRESENT BY
❑ BUILDING o o - 59. 255
I, as owner of the property, or my employees with ADDRESS '
wages as their'sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY ' O a 2 2-8 5-
7044, Business and Professions Code).' MOVING- - TEL. `
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project'(Sec- ADDRESS
tion 7044, Business and Professions Code).
-REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
YARD HWY
hereby affirm that there is a construction.lending agency for FRONT
the performance of the work for which this permit is issued P.L. "
(Sec. 3097, Civ. C.). SIDE
P.L..
Lender's Name
o LDMA Ref. #
m P.C. Fee-$-- _ Permii Fee
Lender's Address _
I certify, that I have.read this.application and state that the Issuance Fee (J Q LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, _ Total Fee � a� LDMA Perm. # - -
v and hereby authorize representatives of this County to enter
upon the'above-menti�ed property for inspection purposes.
22'SS� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature f Applicant or Agent - Date -• - - "" -- - - - _ -
i