HomeMy Public PortalAbout4832ALESSANDRO AVE_Building (3) I WORKERS COMPENSATION DECLARATION
I_hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT,
i�i3�r� Com
or a certificate of Workers Compensation Insurance ,
or b ce tified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polity I , Company ,
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN - _ ADDRESS,
BUILDING &L�Sft���
❑ Certified copy is filed with the county building inspec - BUILDING - - -
tion department ADDRESS I � /-7(I� /I
�
' CITY I/i ,`` �� ZIP le-0 LOCALITY L C r
Date Applicant _ NO OF BLDGS / NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOTS (LG— NOW ON LOT CROSS ST J U
COMPENSATION'INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT ' BLOCK LOT NO 3r6-W MAP BOOK ? G PAGE I PARCEL
hundred dollars ($100) or less ) I - rL TEL [rP
OWNER 7 �/f% //i /VNO - USE ZONE
I certify that in the performance of the work for which this �( SPECIAL _ }
permit is issued I sholl,not employ any person in any manner ADDRESS 7-S ,3 � 7T L��3oL &C J1 L st CONDITIONS CL
so as to become subject to the Workers Compensation Laws �±`-�{� O
t CITY /�!7 �� ! ZIP 7 / S L!
Date -° Applicant ARCHITECT OR TEL Y 0
NOTICE TO APPLICANT If after making this Certificate of ENGINEER 02L- ,/L, � NO DISTRICT GROUP CONSTrTYPE ' FIRE ROCESSED BY O
Exemption you should become subject t the Workers �� LU
Compensation provisions of the Labor Code you must forth ADDRESS j� p� t-�
with comply with such provisions or this permit shall be ^-�- /y �r TEL ��r STATISTICAL CLASSIFICATION APT CONDO N
deemed revoked r r CONTRACTOR 1 �j �i NO Z�// - z
LICENSED CONTRACTORS DECLARATION NO C ✓ 2 CLASS NO DWELL UNITS
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS / �(/ Af S
(commenting with Section 7000)of,�Drvision 3 of the Business �
LIC SEWER MAP
and Professions Code and my license is in full force an ffect CITY /J V p f
CLASS BK J VALIDATION
License Number �- � Lic Class
SIZE �� STORNO IES / FAMILIES ONE
K
-W - VALUATION 1
Contractor Date DESCRIPTION OF WORK - NEW ❑ ; lti ), 0 v ,i w
El am exempt under Sec 11I-L '1" -1- V ADD- 1:1t .e
B&P C for this reason - - s r _ ALTER E] - 96.(
S $REPAIR ❑ J307 �
Date ,
EXISTING BLDG S DEMOL ❑ 1 ITEMS "
Signature APPLICANTT TEL FINAL w c
DATE
OWNER BUILDER DECLARATION (PRINT) NO T I AL �"
I hereby affirm that I am exempt from the Contractor s License 967
Law for the following reason (Section 7031 5 Business and ADDRESS FINAL C" i
Professions Code) S A Y '
�_ PRESENT 1 � By t z ��� ,
ElBUILDING {
I as owner of the property or my employees with ADDRESS" 1 yr� t =
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section LOCALITY v � ty- j�i
7044 Business and Professions Code ) - MOVING TEL _ v OWG-
:i1twI as owner of the property am exclusively contracting CONTRACTOR NO i 57 23 1 AM 9:11-
with
ith licensed contractors to construct the project (Sec - - - -
tion 7044 Business and Professions Code ) ADDRESS
REQUIRED TOTAL SETBACK FROM v EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH r i ti^, �•\ '
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P L
(Sec 3097 Civ'C ) SIDE _ r
Lender s Name
LDMA Ref
Lender s Address
PC Fee$ Permit Fee -U .J C�
pool
1 certify that I have read this application and state that the Issuance Fee O LDMA P/C# v
above information is correct 1 agree to comply with all County Investigation Fee C
ordinances and State jaws relating to building construction Total Fee 6 �J + LDMA Perm #
a and hereby authorize representatives of this County to enter
upon the above mentioned property for inspection purposes t _
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date r 5 ~