HomeMy Public PortalAbout4844ALESSANDRO AVE_Building (3) -IMF - _ I A
ORKERS C SATION DECLARATION
nt to se
insure boraa certif carte of Worke srtComtpensat on eInsuran elf APPLICATION FOR BUIL®I NO PERMIT
or a certified copy thereof (Sec 3800 Lab C )
Policy No Company COUNTY OF LOS ANGELES BUILDING AND SAF TY
BUILDING
❑ Certified copy is hereby furnished ' , FOR APPLICANT TO FILL IN ADDRESS '
❑ Certified copy is filed with the county building inspec BUILDING /l
tion department ADDRESS
Date Applicant CITY P(,tr ZIP 170`
V LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST r
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST
1 (This section need not be completed if the permit is for one ASSESSOR
y3 hundred dollars ($100)or less ) TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL
TEL MAP
OWNER L�
a I certify that in the performance of the work for which this E li NO�S� USE ZONE
� ✓� NO ,
permit is issued I shall not employ any person in any manner �� S SPECIAL
so as to become subject to the W ADDRESS Workers Compensation Laws y� CONDITIONS O
DateJ 6 CITY ZIP
7- App Icont 0'
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TELENGINEER + NO� � DISTRICT GROUP TYPE FIRE PRO SSED BY O
Exemption you should become subject to the Workers r^f CONST ZONE V
Compensation provisions of the Labor Code you must forth ADDRESS
with comply with such provisions or this permit shall be - TEL
deemed revoked CONTRACTOR NO STATISTICAL CLASSIFICATION APT rNDO U)LICENSED CONTRACTORS DECLARATION LIC CLASS NO' DWELL UNITS Z
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 P
Professions Code and my license is in full force and effect CITY CLASSVALIDATION
SQ FT N OF ` NO OF CHECK BK `� PG
License Number Lc Class SIZE 3;?0 ISTORIES FAMILIES ONE
El VALUATION
Contractor Date
s ` DESCRIPTION OF WORK NEW
❑ I am exempt under Sec o(-) -,vA 1� 101/}��! 0 ADD $
ALTER ❑ j
B 8P C for this reason REPAIR ❑ $
Date USE OF
EXISTING BLDG DEMOL ❑
Signature - - + _ APPLICANT TEL 9� 9 9 1 8 A
OWNER BUILDER DECLARATION (PRINT) FINALDATE
I hereby affirm that I am exempt from the Contractor s License # `0 0 0 • •
Low for the following reason (Section 7031 5 Business and ADDRESS tfetFIN ) o - 4988
Professions Code) ' B 0 0 0 49885
I as owner of the property or my employees with BUILDING ADDRESS ,
wages as their sole compensation will do the work and `
the structure is not intended or offered for sale(Section LOCALITY ® j 0 61 7-88
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
tion 7044 Business and Professions Code) ADDRESS C S n
L SETBA
SET BACK YARD
CONSTRUCTION LENDING AGENCY REQUIRED -HWY TOTAL
LINE WIDTH
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
PL
Lender s Name
m PC Fee E PermitFee
LDMA Ref #
Lender s Address r _
I certify that I have read this application and state that the Issuance Fee LDMA P/C# ® _
above information is correct I agree to comply with all County Investigation Fee ti
8 ordinances and State jaws relating to building construction , Total Fee ql
1 LDMA Perm #
$ Qnd hereby authorize representatives of this County to enter
up a above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant-o-r-Axje"s. Dote