HomeMy Public PortalAbout4848ALESSANDRO AVE_Building (3) JNORKERS' COMPEISA71G1V'DECLARAT ION
affirm that I have a certificate of consent to self
or a cerl'ficat�of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lob. C.) --. -
COUNTY.OF LOS ANGELES BUILDING.AND SAFETY
Policy No. CompanyBUILDING
,yry
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDING ¢ �y
tion department. ADDRESS (elf �� 0✓ Z?
Date Applicant CITY jam! c' 1 � ZIP I�� LOCALITY � � /�
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT srfl L L— NO. OF BLDGS. NEAR
NOW ON LOT f CROSSSST. r i
COMPENSATION INSURANCE J� P
(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 t
TEL r USE ZONE MAP
OWNER f-t gS p'i,� ' �.' NO (T 17�
I certify that in'the performance of the work for which this t} 4 NO• �.
permit is issued,'I shall not employ any person in any manner ADDRESS y 1 �e-c 1V rG !� SPECIAL
so as to become subject to the Wor rs'Compensati' p Laws. CONDITIONS
Date Applicant / CITY P ��! l' / l ZIP' �� 0
ARCHITECT OR TEL. DISTRICT GROUP .TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, ma ing tthis Certificate of ENGINEER NO. CONS ZONE
Exemption, you should me subject to the Workers' �+ W
Compensation provisions o the Labor Code, you must forth-
ADDRESS
with comply with such provisions or this, permit shall be - TEL. STATISTICAL CLASSIFI ATION APT.// CONDO.
deemed revoked. CONTRACTOR NO.
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. NO. OF_ NO. OF / CHECK
License Number Lic.Class' SIZE 5� STORIES f FAMILIES ( ONE
�( VALUATION
Contractor Date DESCRIPTION OF WORK '/' ' 'v D' C NEW- ❑ /� ,/y V '�
ADD ® S "i/ ,
❑ I am exempt under Sec. J ` rf ❑
-ALTER
B.&P.C. for this reason REPAIR ❑ S
Date: USE OF F,S DEMO" ❑ !
EXISTING BLDG.
Signature APPLICANT TEL
d FINA
9 PRINT) j�M4.' j Ru bt NO.2-�5 Ip r
OWNER-BUILDER DECLARATION DATE 2 6 5$3 A
I hereby affirm that I am exempt from the Contractor's License Alaw for the following'redson (Section 7031.5, Business and ADDRESS ' -I u / <-S s � r' FIN
Professions Code): PRESENT q j C' V' BY # 0 0 0 0 0•1
BUILDING � ry�/ ,.,`I�(1r- /Q ,.
® I, as owner of the property, or my employees with ADDRESS �/� C-1 2 4 8 8
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING { MQ1 f��P No �+�y� f 0/2 '' ° ° 1 2�l.8 8 "
aI, as owner of the property, am exclusively contracting CONTRACTOR(/ / 6J d tJ
with licensed contractors to construct the project (Sec- ADDRESS y��`F_S S CI �V L l7 2 2 6—'8 7
tion 7044,'Business and Professions Code).
CONSTRUCTION LENDING AGENCY' ' SET BACKD YARD HWY TOTAPREOPAINEFROM WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for-which this permit is issued - P.L.
(Sec. 3097, Civ. C.). SIDE
m
P.L.
Lender's Name
LDMA Ref. #
- P:C. Fee$ - - - Permit Fee - --
Lender's Address
> oil,I certify that I have read this application and state that the Issuance Fee• s !DMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee
u and hereby authorize representatives of this County to enter LDMA Perm. #
-
m :up7the above-mentio property for inspection purposes.
d
a 1 9/,1i -2. SEE REVERSE FOR EXPLANATORY LANGUAGE
v Signature of Applicant or'Agent ' Date - --- - - - Oo