HomeMy Public PortalAbout4908ALESSANDRO AVE_Building (5) o _ WORKERS' COMPENSATION DECLARATION
�i , e`6, a cer that I have r certificate of consent to self APPLICATION FOR, ,BUILDING PERMIT
in;uPe, or a certificate of Workers' Compensation Insurance,
ol a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.— Company
❑ Certified copy is hereby urny fished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING / nA
�r
tion department. ADDRESS
,� / �/J�j�L� V7
Date Applicant CITY /j7,ALc ZIP LOCALITY
i NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT Q NOW ON LOT CROSS ST.
COMPENSATION INSURANCE / ASSESSOR
(This section need not be completed if the permit is for one TRACT 6� BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.)
OWNER USE ZONE MAP /_
I certify that in the performance of the work'for which this p NO.
permit is issued, I shall not employ any person in any manner ADDRESS L� q eo �/ SPECIAL d
CONDITIONS
so as to become subject to the Workers'Compensation Laws. �A O
CITY 0 CZ rY ZIP / U U
Date Applicant, Al SK' 0// 1' S ARCHITECT OR TEL. 0
DISTRICT GROUP TYPE FIRE CESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO
CONST. ZONE O
Exemption, you should become subject ,to the Workers' �V
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
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
LIC. SEWER MAP
and 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 STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑
`A - ADD
❑I am exempt under Sec. .-Gtr_
_ ALTER ❑
B.&P.C. for this reason $
REPAIR ❑
Date: USE OF
EXISTING BLDG. DEMO' ❑
Signature APPLICANT TEL. FINAL Q V
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
ofessions Code): PRESENT By
ACCT.
n�(
I, as owner of the property, or m employees with BUILDING i'11.0 °T
P P Y� YADDRESS
wages as their sole compensation,will do the work and 3307 96.75
the structure is not intended or offered for sale(Section LOCALITY pool7044, Business and Professions Code.) MOVING TEL. 1 ITEWS
❑ I, as owner of the.property, am exclusively contracting CONTRACTOR NO.
with licensed contractors.to construct the project (Sec- TOTAL 96.75
ADDRESS
tion 7044, Business and Professions Code.) � C
REQUIRED TOTAL SETBACK FROM EXIST. CHECK
�` 7❑6O7�r
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH CHANGE
i
I hereby affirm that there is a construction'lending agency for FRONT CHANGE .011
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.Lender's Name ry i A8/22f 89
LDMA Ref. # .5.20 1 5 A S 8 2
- P.C. Fee$ ermit Fee
pop Address
0 1 certify that I have read this application and state that the Issuance Fee , Q LDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee
R ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
nd her out on a representat' s of this County to enter
up th bove- entioned pr er for inspection purposes.
SEE REVERSE FOR EXPLANATORY LAN UAGE
S. ure of Applicant or Agent Date