HomeMy Public PortalAbout4908ALESSANDRO AVE_Building (4) WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, oP a certificate of Workers'.Compensation Insurance, A P P L I CAT I N -FOR BUILDING PERMIT
or a certif:d copy thereof (Sec. 300, Lab. C.) K COUNTY OF COS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING % p
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS G
❑ Certified copy is filed with the county building inspec- ADDRESS lt29 it�L,ES9 vk ��.�LO S� '
tion department. a
Date Applicant CITY r CAZBLD6)'-1 D LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT NEAREST
CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This ;.r-tion need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK �� PAGE PARCEL
hundred'dollars ($100) or less.) El.
OWNER ! O, USE ZONE MAP �ycf,�; �
I.cert�fy that in the performance of the work for which this `� / SPE
permit is issued, I shall not employ any person in any manner ADDRES G I JJ _ / SPECIAL a-
CONDITIONS
so as to become subject to the Workers'Compensation Laws. 0
CIPf'�/0i0 Z_ (%/ ZIP
Date Applicant ARCHITECT OR TEL. // DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER OCe) l NO Y
' CONST. ZONE U
Exemption, you should become subject. to .the Workers' G
Compensation provisions of the Labor Code, you must forth- ADDRESS y�J��O - ;_i `�� N
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO.
deemed revoked. CONTRACTOR, J� Z
NO. � �J —
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division-3 of the Business
LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT." �t NO. OF NO. OF / CHECK
License Number Lic. Class SIZE V STORIES FAMILIES ( ONE.
VALUATION
Contractor Date
DESCRIPTION
OFF WORK
–b/ no,1 O lam) NEW El E �7 ,--�U • ��"' -
( B /5 ! �/Or�l S I /J. �'7 '- ADD 6 c%._.. ,,
❑I am exempt under Sec. (y i_
ALTER, ❑ � I '$
B.&P.C. for-this reason e t -
s Q i`7�.�/7 REPAIR ❑ $ `i Q.`J
Date: USE OF
D
EXISTING BLDG. DEMOL ❑ y e
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 FINAL _
Professions Code): PRESENT By HENS
BUILDING ;
I, as owner of the property, or my employees with ADDRESS �S' �� ;Y; `
wages as their sole compensation,wil l'do the work and ` f'' 'ril" "
LOCALITYT - , , r•t'�;.:,•
'- the structure is not.intended or offered for sale(Section s. '�°�� � � 6
MOVING TEL. = - �* r ir.44
7044, Business and Professions Code.) - � _.•
CONTRACTOR NO. i
❑ I, as owner of the property, am exclusively contracting HANGS
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions.Code.) I ADDRESS t.
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. ;_ 's ;-t sa�; �'
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH a ; 51.
I hereby affirm that there is a construction lending agency for FRONT T- K: I.r�
the performance of the work for which this permit is issued P.L. �:}:''? Ir
(Sec. 3097, Civ. C.). SIDE
P.L.'
Lender's Name LDMA Ref. # 1
P.C. Fee$ /S Permit Fee
3 Lender's Address y ►
�1 certify that I have read this application and state that'the Issuance Fee � / LDMA P/C#
above information is correct..)agree to comply with all County Investigation Fee_
6 ordinances and State laws relating to building construction, Total Fee CP� LDMA Perm. #
a �an� eleby authorize representatives of this County to enter
upon ab ve entioned properT for inspection purposes.
a o
�3 SEE REVERSE FOR EXPLANATORY LANGUAGE
Stena Applicant or Agent Date