HomeMy Public PortalAbout4839ALESSANDRO AVE_Building (4) WORKERS' COMPENSATION DECLARATION _ i
/'�nsureor ofcert f cote of ? f Comtpenof consnt to se��
saHon ensuran elf APPLICATION FOR BUILDING PERd IT
/J or.a cerrKied copy thereof (Sec. 38Lab. C'XX .) COUNTY OF LOS ANGELES BUILDING AND SAFETY .
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING 461 u�, , 5 •�
F1Certified copy is filed with the county building inspec- BUILDING / L
ADDRESS
tion department. ADDRESS 3 L D eD 5 7
Date Applicant CITY�� / T ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS T. LA ZZy.56
(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 C S'/ USE ZONE MAP
I certify that in the performance of the work for which this OWNER LI ESC NO. NO.
permit is issued, 1 shall not employ any person in any manner SPECIAL
so as to become subject to the Worker ' ompensation Laws. ADDRESS 3 - a/A/�!)iV.� S C� T7 ` CONDITIONS
CITY G,417�A ZIP 9j a 06
Date V Applican� - ^� ARCHITECT OR TEL.
NOTICE TO APPLI ANT: If, after making this Certificate of ENGINEER � CL j ,�" O. ,-!,(�j DISTRICT GROUP TYPE FIRE R ESSED BY
Exemption, you should become subject to the Workers' / ✓ CONST. ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS I 1� O�� S ,C�r
with comply with such provisions or this permit shall be
TEL. STATISTICAL CLASSIFICATION APT. CONDO.
deemed revoked. CONTRACTOR 0 to��
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. OF NO.OF NO. CHECK
License Number Lic.Class SIZE STORIES / FAMILIES / ONE
NEW
VALUATION
Contractor Date DESCRIPTION OF WORK ❑
e 0 ADD ❑ S O
❑ I am exempt under Sec. I `i ❑
ALTER LU
B.BP.C. for this reason REPAIR ❑ $ 0,
Date:
USE OF ❑
EXISTING BLDG. DEMOL �.
Signature APPLICANT TEL. FINAL '
OWNER-BUILDER DECLARATION (PRINT) NO. DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINA
Professions Code): PRESENT BYBUILDING
•
I, as owner of the property, or my employees with ADDRESS XT.
,
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY - 3y_;•-i j;R UI;jn ;
r-� 7044, Business and Professions Code). MOVING TEL.
I% I 1, as owner of the property, am exclusively contracting CONTRACTOR NO. «Y
with licensed contractors to construct the project (Sec- ^i;<<�L_g;111;y r'
tion 7044, Business and Professions Code). ADDRESS :=L tr' it r-i
REQUIRED TOTAL SETBACK "r? -;
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH .ty i Alt °i==
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.I.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Nome
� LDMA Ref. #
m Lender's Address P.C. Fee$ Permit Fee
3 C
$ I certify that I have read this application and state that the Issuance Fee !S^� LDMA P/C#
o above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State lows relating to building construction, Total Fee O/J LDMA Perm. #
and here y authorize representatives of this County to enter
m upon th abovZ!, nned prop rty for inspection purposes.
M SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date