HomeMy Public PortalAbout4941ALESSANDRO AVE_Building (7) I WORKERS COMPENSATION DECLARATION
I insurebor affcertif carte ofaWo ke srtCompensation eInsuran elf APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C ) i 'fl
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polcy1No 1046140 Company State Fund -
Cer ified co is hereby furnished BUILDING
copy y FOR APPLICANT TO FILL IN ADDRESS
x❑ Certified copy is filed with the county building inspec BUILD
INC,, `
tion department ADDRES�t94r Alessandro, T C 91780
Date 11-1-88 Applicant Randol Roofing CITY ZIP 91790 LOCALITY
CERTIFICATE OF'EXEMPTION FROM WORKERS NO 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 ) t TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL
'1 TEL
OWNER USE Z E MAP
{ I certify that in the performance of the work for which this N — ( NO
permit is issued I shall not employ any person in any manner I SPECIAL
so as to become subject to the Workers Compensation Laws ADDRESS Same As Above CONDITIONS
3-2-88 Randol roofing r CITY ZIP
U
Date Applicant
t NOTICE TO APPLICANT If o-after making this Certificate of ARCHITECT OR TEL DISTRICT GROUP TYPEFIRE PR SSED BY Q
ENGINEER NO
Exemption you should become subject to the Workers t^� CONST ZONE I—
Compensation provisions of the Labor Code you must forth ADDRESS W
with comply with such provisions or this permit shall bea,
deemed revoked TEL STATISTICAL C IFICATION V . y APT C DO N
CONTRACTOR Randol Roofin No288-4040
LICENSED CONTRACTORS DECLARATION _ CLASS NO DWELL UNITS Z
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 529 E Valley Blvd No 451937
(commencing with Section 7000)of Division 3 of the Business and UC SEWER MAP
Professions Code and my license is in full force and effect CITYSan Gabriel, Ca 91776 'CLASS C-39BK I VALIDATION
451937 C-39 SQ FT NO OF NO OF CHECK PG
License Number k Lc Class SIZE STORIES FAMILIES ONE
' VALUATION
Contractor Randol` Roof in?Date 3-2-58 DESCRIPTION OF WORK — NEW ❑ $
1985 00
1 am exempt under Sec fiberglas shingles, Class A ADD ❑ ,
ALTER Co:]
B 8P C for this reason Roof REPAIR $
Date USE OF
EXISTING BLDG DEMOL
Signature APPLICANT TEL FINAL
OWNER BUILDER DECLARATION PRINT Randol Roofing NO 288-4040 DATE Zl j
I hereby affirm that I am exempt from the Contractor s License ADDRESS 529 E Valle Blvd S yG 91776
i Law for the following reason (Section 7031 5 Business and
Professions Code) - FRtbtN1 - Y
❑ BUILDING
I as owner of the property or my employees with ADDRESS
swages as their sole compensation will do the work and ;291 9�9 A
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code) ''S MOVING TEL ��
I as owner of the property am exclusively contracting CONTRACTOR NO o o Oil
with licensed contractors to construct the project (Sec t _ #
tion 7044 Business and Professions Code) ADDRESS 0 0 4 9 8 8
`CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETBAC
SET BACK YARD HWY PROP LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT a o 0 4(� 8 8
the performance of the work for which this permit is issued P L
(Sec 3097 Civ C ) SIDE
PL p318a'88
Lender s Name
LDMA Ref #
Lender s Address PC Fee$ Permit Fee Y
Y
I certify that I have reod,this application and state that the Issuance Fee C LDMA P/C q ti
o above information is correct I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building constructionI�Feel4988
T
$ and he aur n representatives of this County to enter LDMA Perm #
upon e v do prop y f inspection p rpo es
m ..
/— 0 SEE REVERSE FOR EXPLANATORY LANGUAGE "
Signature of Applicant or Agent e