HomeMy Public PortalAbout4941ALESSANDRO AVE_Building (6) �r 1-+dORKERS COMPENSATION DECLARATION
herek affirm that 1 have a certificate of consent to self APPLICATION FOR BUILDING PERMIT
insusure or a certificate of Workers Compensation Insurance
or((��a terttified copy thereof (Sec d800 Lab C )
PN (>'bd�311 � Company Yl N�SiND► COUNTY OF LOS ANGELES BUILDING AND SA ETY `
El 'Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with the county building mspec BUILDINGWt/1
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tion deportment a ADDRESS '7/
Date Applicant CITY ZIP b LOCALITY
CERTIFICATE OF EXEMPTION ROM WORKERS N OF BLDGS NEAREST
COMPENSATION INS RANCE SIZE OF LOT ONOW ON LOT 2— CROSS ST
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less ) , t TRACT �'+ BLOCK LOT NO MAP BOOK PAGE PARCEL
` OWNER L {�fLU �� NO
TEL xd5- USE ONE MAP
I certify that in the performance of the work for which this 77 y NO
permit is issued I shall not employ any person in any manner ADDRESS " } SPECIAL
so as to become subject to the Workers Compensation Laws 'S' CONDITIONS 0
U
Date Applicant 4 CITY \ ZIP
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR q
ENGINEER / TEL DISTRICT GR UP TYPE FIRE PR ED BY 0
t
Exemption you should become subject to the Workers NO CONST ZON V
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Compensation provisions of the Labor Code you must forth ADDRESS , i "� V e W
with comply with such provisions or,this permit shall be D-
deemed revoked TEL �/ STATISTICAL CLASSIFI ATION APT NDO fn
CONTRACTOR NO �'T L Z
" LICENSED CONTRACTORS'DECLARATION jj��yyLIC CLASS NO � DWELL UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �► �1LN0
(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 -9 BK PG 3-7 VALIDATION
SQ FT/61 NO OF NO OF CHECK
License Number Lic Clas SIZE O SCJ STORIES FAMILIES ONE
hr h_S Hl _ 172 Sq r,,�., VALUATION
Contrac,_r ate DESCRIPTION OF WORK 1NEW
C l�
I am exempt under Sec ADD
/I ALTER
B&P C for this reason /& REPAIR 0 $
4 Date U E OF O
EXISTING BLDG j (�"�CDEM
� OL
Signature ! APPLICANT �� TEL 7 p FINAL
OWNER BUILDER DECLARATION PRINT (\vp (On+� NO l ZV ( DATE
I hereby affirm that I am exempt from the Contractor s License 7 5 4 b A
Law for the following reason (Section 7031 5 Business and ADDRESS?/-? kM1Q& W /)L`�— FINA 3
Professions Code) By
V117'a-1
BUILDING
I as owner of the property or my employees with ADDRESS i • - 8738
wages as their sole compensation will do the work and s $ 7 3$_
the structure is not intended or offered for sale(Section LOCALITY 1 l o o • 6
7044 Business and Professions Code) MOVING TEL
a ,
I as owner of the property am exclusively contracting CONTRACTOR � 0 �.
728 $7
with licensed contractors To construct the project (Sec ADDRESS tL`
Tion 7044 Business and Professions Code) �� M
REQUIRED TOTAL SETBACK _
' CONSTRUCTION LENDING AGENCY SET BACK YARD HWY 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 t ,
(Sec 3097 Civ C ) SIDE
All A- PL t r
Lender s Name t
m —r LDMA Ref #
m P C Fee b Permit Fee
Lender s Address
I certifythat I have read this application and state that the `
PP Issuance Fee LDMA P/C#
above information is correct I agree to comply with all County Invest+gation Fee
S ordinances and State jaws relating to building construction 1
R an hereby authorize representatives of this County to enter Total Fee LDMA Perm #
m
up
o the above meLnti ed property for inspection purposes
t0 y
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
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