HomeMy Public PortalAbout4839ALESSANDRO AVE_Building (3) WORKERS' COMPENSATION DECLARATION
insure,hereby
aafcertif cafe of Workers' Compensation Insuran of A P P L I CATIONFOR U 11 D I N G. PERMIT
a _
or certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
FXMPF56-225154 . CompanylTremont Indemnity
Certified copy is hereby furnished., FOR APPLICANT TO FILL IN BUILDING K31 /Ip
ADDRESS / c(/
® Certified copy is filed with'the county building inspec- BUILDING
tion department.. ADDRESS 4839 .N. Alessandro
Date -8/12/85 Applicant CITY Temple Cit ZIP LOCALITY Ny-im", ez
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST -
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. U 0 ZONE MAP
( .
' I certify that in the•performance of the work for which this OWNER Romeo B1SSOri NO. NO. >_
permit is issued,.I shall not employ any person in any manner SPECIAL 9L
ADDRESS 4839 N. Alessandro CONDITIONS O
so'as to become subject to the Workers'Compensation Laws. lJ
Date Applicant CITY Temple Cit ZIP 09
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT G UP TYPE FIRE PROCESSED BY O
ENGINEER NO. CONST.. / ZONE tj
Exemption, you should become subject to the Workers' 0�\/ (// �
Com ehsation provisions of-the Labor Code, you must forth- �/`V `� 9116
withcomply with such provisions or this permit shall be ADDRESS TEL H
deemed revoked: STATISTICAL CLASSIFICATION APT. NDO. z
CONTRACToVir in Roof NO
LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. DWELL.:UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESSP•0' BOX J No1606 50
(commencing with Section 7000)of Division 3 of the Business andLIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY San Gabriel, CA. C39
CLASS VALIDATION
SQ.-FT. NO. OF NO. OF CHECK BK. PG.
license Number 160650 Lic.Class" C'39 SIZE STORIES FAMILIES ONE
VALUATION_
Contractor Virgin Roof Cvc.e 8/12/R5 DESCRIPTION OF WORK NEW E] $ 1199.00
I am exempt under Sec.
my with #220 Composition ADD E]s pill.
.
B.&P. ing es6 0 C. for' reason q REPAIR. $
Date: USE OF ❑
EXISTING BLDG. OL
DEM
Signature APPLICANTEL. FINAL
OWNER-BUILDER DECLARATION PRINTVir In Roof CO. NO. 287-0507 DATE "Zjv?
I-hereby affirm that I am exempt from the Contractor's License ADDRESS
.O BOX J,San Gabriel,CA. 9
Law for the following reason (Section 7031.5, Business and F L
Professions'Cod'e): PRESENT By 16
OBUILDING
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
7044, Business and Professions Code). MOVING TEL.
I, as owner of the property, am exclusivelycontractingCONTRACTOR NO.
with licensed contractors to construct the project Sec-
ADDRESS 0 0 0
tion 7044, Business and Professions Code). 0 a 2 2 s 8 5
REQUIRED YARD HWY TOTAL SETBACK FROM. EXIST.
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDT
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
m P.L.
Lender's Name
o' LDMA Ref. #
m - - P.C. Fee$ Permit Fee 39•.38 -
Lender's Address 0.50
t I certify.that I have read this application and state.that the Issuance Fee- LDMA P/C# -
a above information is correct. I agree to comply with all County Investigation Fee
m ordinances and State laws relating to building construction,
u and hereby authorize representatives of this County to enter Total Fee 4-9.88 LDMA perm. #
upo abov m nt'on prop rty for inspection purposes.
a 2�S,r SEE REVERSE FOR EXPLANATORY LANGUAGE
- - gnature o Applicant or Agent - Date