HomeMy Public PortalAbout4923ALESSANDRO AVE_Building (5) WORKERS' COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self q p p CATION FOR BUILDING p E RM I T
nsure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, L'ab:C.)
COUNTY OF LOS ANGELES BUILDING.AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
ElCertified copy is filed with the county building inspec- BUILDING
tion department: ADDRESS
Ddte ApplicantCI �% ZIP LOCALITY -
CERTIFICATE OF EXEMPTION FROM WORKERS','. O. OF BLDGS, NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST._.
(This section'need not be completed if,the,permit is-for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. / MAP BOOKTEL PAGE PARCEL
OWNER `�d NO" �gb ^3Y USE ZONE MAP
I.certify that.in the performance o_f the work for which this NO. r
permit is issued, I shall not employ any person in any manner it SPECIAL - tZ
sd'as'to e;7i
ubject to the War Compensation Laws. ADDRESS CONDITIONS CI e' ZIP
Date Applicant ARCHITECT OR TEL. Q
NOT f TO APPLI ANT: If, of r making this*Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE , PROCESSED BY --,
Exemption, you should be' me subject to 'the Workers' CONST. ZONE V
Compensation provisions of.the Labor Code, you must forth- ADDRESS CL
with comply with such provisions or this•permit shall be N
TEL. STATISTICAL CLASSIF CATION T. CONDO. aZ
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 7 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 VALIDATION
SQ. FT. NO. OF NO. OF CHECK BK. PG.
J.License Number Lic.Class SIZE STORIES FAMILIES / ONE
C— S Q E NEW ❑ LUATION
Contractor Date DESCRIPTION OF WO ��
ADD ❑
❑ I am exempt under Sec. '- � � — �E — 00 r ❑ , '- .
.,, ALTER ,
B.&P.C. for this reason REPAIR ❑ $
I- USE OF
Date: EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT) NO.
_ DATE
I hereby affirm that 1 am.exempt from the Contractor's License
Low.for the following•reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT By c 2 0 O.3 A
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS 1# 0,0 0 0'0,1
wages as their sole compensation,will do the work and +
the structure is not intended or offered for sale(Section LOCALITY o 0
7044, Business and Professions Code). MOVING TEL. ' •2, v 4 Q'S 0' --CONTRACTOR NO.
❑ I, as owner of the property, am exclusively contracting o 0 0 (� 0,50 v
with licensed contractors to construct the project (Sec- ' ' t
tion 7044, Business and Professions Code). ADDRESS 06 1 4-84
REQUIRED YARD HWY TOTAL SETBACK FROM IST.
CONSTRUCTION LENDING AGENCY' SET BACK PROP. LINE 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
^ P.L. i
Lender's Name
o LDMA Ref. #
-- P.C. Fee$ -- Permit Fee -
Lender's Address
> I certify-that I have read this application and.state that the CC ' -
PP - -- Issuance Fee - LDMA P/C#
a above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to-building construction,
and her by authorize representatives of this County to enter Total Fee LDMA Perm. # - --
on t above-mentioned property for inspect/iq n urpo es.
�(�✓C, ✓ �F' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent - Date'- - - - - - --• - - -