Loading...
HomeMy Public PortalAbout4905ALESSANDRO AVE_Building (3) WORKERS COMPENSATION DECLARATION ,w t{ 7, r J� I hereby affirm that I have a certificate certifof consent t6 APPLICATION FOR BUILDING PERMIT self � insure or a certificate of Workers Cocate of Insurance or a certified copy thereof (Sec 3800 Lab C -CS111306�?, Ma.ry�land Casualty COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N pany n Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS BUILDING Certified co is filed with the count building inspec ` X PY Y 9 P BUILDING tion department �, ADDRESS 4905 Alessandro LOCALITY NEAREST Date Applicant CITY Tem le C3-ty ZIP 91780 CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERSf 61X110 NOW ON LOTS 1 MAPSS PAGE PARCEL COMPENSATION INSURANCE SIZE OF LOT NO OF (This section need not be completed if the permit is for one i USE ZONE MAP TRACT � BLOCK LOT NO ! NO hundred dollars ($100)or less ) 1 } � TE I� SPECIAL d, I certify that in the performance of the work for which this OWNERM .Kenneth Tse N,1,86-6989 !- CONDITIONS 0 permit is issued I shall not empA'pn in any er 4905 Alessandro DISTRICT GROUP TYPE FIRE PR E U Q� � CON ZONE so as to become subject to the pensai s ^ ADDRESSd VOCITY Temple City ZIP 91780 ✓)Date ApplicaSTATISTICAL CLASSIFICATION APT CONDO—] NOTICE TO APPLICANT If aft s Certificate of ARCHITECT OR TEL --���I��//yyyyyy /' W ENGINEER none NO CLASS NODWELL UNITS d Exemption you should become subject to the Workers � N Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP with comply with such provisions or this permit shall be ^,,, �' deemed revoked CONTRACTOAmerican Bullde4 287-9744 BK �/ PG 3 VALIDATION LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 5819 2TempleCityBl c104325 VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC1 Q 0 - Professions Code and my license is in full force and effect CITY Te City lt B- $ CLASS 3 f-3 o0 -- 1 �{ SQ FT NO OF NO OF t CHECK License Number104325 Ltc Class B-1 SIZE STORIES FAMILIES 1 ONE ContracloAmeri.can Bulldgj;�s 11/21/80, t DESCRIPTION OF WORK NEW ❑ I am exempt from the licensing requirements as I am a I Second Story Addltlon ADD licensed architect or a registered professional engineer ALTER ❑ FINAL acting in my professional capacity (Section 7051e at REPAIR ❑ DATE Z �I Business and Professions Code) 1 USEOF AL _ EXISTING BLDG Dwelhng DEMOL ❑ By Lic or Reg No Date APPLICANT T L �J (PRINT) American Builder,, 287-974 , ' OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor s License p �� Law for the following reason (Section 7031 5 Business and ADDRES�019� Te leCit Blvd T.C.O Ca Professions Code) PRESENT } BUILDING 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 I p 7044 Business and Professions Code) MOVING TEL 1 as owner of the property am exclusively contracting CONTRACTOR NO with licensed contractors to construct the project (Sec ADDRESS � b 1 7 A \ tion 7044 Business and Professions Code) r 1 REQUIRED TOTAL SETBACK FROM EXIST / 0 0 0 0 0 \ CONSTRUCTION LENDING AGENCY f SET BACK YARD HWY PROP LINE WIDTH # 1 I hereby affirm that there is a construction lending agency for 1 FRONT D © D / 2 0 3 (� b O 0 the performance of the work for which this permit is issued P L (Sec 3097 Civ C ) SIDE ` PL e o 346,00 Lender s Name ' Lender s Address P C Fee$ e�74 ""0 Permit Fee 0 1, 0 5-8 1� ` w I certify that I have read this application and state that the t Issuance Fee °- above information is correct I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building,construction Total Fee 93 and hereby authorize represent tives of this County to enter t Qupan.i Wn afor inspection purposes a B 11/21/80 SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature App scant or Agent Date 0_ 1 ��