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HomeMy Public PortalAbout4902ALESSANDRO AVE_Building (5) WORKERS COMPENSATION DECLARATION / 'I y r " APPLICATION FOR BUILDING PERMIT - J� hereby affirm that I have a certificate of consent to self sure or a certificate of Workers Compenstion Insurance or certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY olicy No Company 5 Certified copy is hereby furnished FOR APPLICANT TO FILL IN rASSESSOR C/ 6� - Certified copy is filed with the county building inspec BUILDING G tion department ADDRESS ilT C �g D r ! ate Applicant CITY G Ac C / ) ZIP CERTIFICATE OF EXEMPTION FROM WORKERS t NO OF BLDGS COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT PAGE PARCEL his section need not be completed if the permit is for one USE ZONE MAP , undred dollars ($100)or less TRACT - TT11 BLOCK LOT NO V NO ECIAL `d I certify that in the performance of work for which this OWNER.P,9 i✓fJ S�''tSd CONDITIONS p } - O ermit is issued I shall not employ any person in any manner DISTRIC^T/ GROUP TYPE FIRE PROCESSED BY V o as to become subject to the Workers Compensation Laws ADDRESS Ig tl CONST ZONE Im O $. CITY L (! !T ZIP /� Gam/ 3 � ate Applicant STATISTICAL CLASSIFICATION AF CONDO V Nmaking NOTICE TO APPLICANT If after this eARCHITECT OR TEL IW rtificate of / CL, ENGINEER NO CLASS NO DWELL UNITS xemption you should become subject to the Workers Vf� =ompensation provisions of the Labor Code you must forth ADDRESS SEWER MPP Z Nith comply with such provisions or this permit shall be '7 Jeemed revoked CONTRACTOR K NOTEL 8 BK J PG 3/ VALIDATION LICENSED CONTRACTORS DECLARATION LIC hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO-3/,f 151 VALUATION 'commencing with Section 7000)of Division 3 of the Business and LIC Irofessions Code and my license is in full force and effect CITY CLASS I $ Q© Q ^L SQ NO OF NO OF CHECK _icense Nuum�ber. -1/00 7 / Lic Class / ?.y SIZE STORIES FAMILIES f ONE i :ontracto�b w, /L� ".0.e—A4, Date ,f'�� �o ✓ DESCRIPTION OF WORK NEW ❑ $ I am exempt from the licensing requirements as I am a or W41 ADD licensed architect or a registered professional engineer ALTER ❑ FINAL acting in my professional capacity (Section 7051 REPAIR ❑ DATE��`,� � } Business and Professions Code) USE OF FINAL EXISTING BLDG DEMOL ❑ 8 Ac or Reg No _Date APPLICANT TEL Y t A OWNER BUILDER DECLARATION (PRINT) NO hereby affirm that I am exempt from the Contractor s License J _aw for the following reason (Section 7031 5 Business and ADDRESS —361 19-5PPti + on 'rofessions Code) - PRE ENT BUILDING I as owner of the property or my employees with I ADDRESS f, wages as their sole compensation will do the work and �1 �\)��^ 2 5 3 7 6 A the structure isnot intended or offered for sale(Section LOCALITY r 7044 Business and Professions Code) t MOVING TEL f (� 0 0 0 • o CONTRACTOR NO R j`�� ti rl n 1 as owner of the property am exclusively contracting with licensed contractors to construct the project (Sec ADDRESS } 2t• " 6 1 0 0 -tion 7044 Business and Professions Code) SJy vttl REQUIRED TOTAL SETBACK FROM EXIST 6 1 O O v CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP LINE WIDTH oto 0 I hereby affirm that there is a construction lending agency for FRONT p the performance of the work for which this permit is issued P L PF a`a1� 0 8 0 3--8 2 (Sec 3097 Civ C ) l SIDE _ ' PL Lender s Name Lender s Address P C Fee S Permit Fees " certify that I have read this application and state that the Issuance Fee a above information is correct I agree to comply with all County Investigation Fee )rdinances and State laws relatingto buildconstruction end hereby authorize representatives building of this County to enter Total Fee .)pan the above mentioned property for inspection purposes f 4 z -• i r.--3 —�v� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of AppIimnt ar A nt Date ®S