HomeMy Public PortalAbout4942ALESSANDRO AVE_Building (2) WORKERS COMPENSATION DECLARATIONhet t
insure bor affcertif carte of Worke srtCompensation eInsurancef APPLICATION F®R BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C ) _
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
❑
Certified copy is hereby furnished , FOR APPLICANT TO FILL IN BUILDING l/�
ADDRESS 7
❑ Certified copy is filed with the county building mspec BUILDING ♦`, /J�f /
tion department ADDRESS
Date $ ~ Applicant CITY �� C/�' ZIP /���� LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGSNEAREST G O SGL
COMPENSATION INSURANCE SIZE OF LOT O NOW ON LOT CROSS ST
(This section need not be completed if the permit is for one TRACT BOCLOT NO ASSESSOR
BLOCK hundred dollars ($100)or less ) MAP BOOK PAGE PARCEL
TEL USE NE MAP
I certify that in the performance of the work for which this OWNER �/ /� / NO — NO
permit is issued I shall not employ any person in any manner /// C�iL � , SPECIAL
so as to become sublect to the Wor ers Comp saADDRESS CONDITIONS tio Laws U
CITY �� G/ ZIP _
Date Applicant
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PRO SSED BY O
Exemption you should become subject to the Workers ENGINEER NO ,l(/ CONST/ ZO E V
Compensation provisions of the Labor Code you must forth ADDRESS U'/U� 9 V
with comply with such provisions or this permit shall be TEL
deemed revoked Z CONTRACTOR NO STATISTICAL CLASSIFI ON APT ONDO Z
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 and LIC _ SEWER MAP
Professions Code and m'y license is in full force and effect CITY y CLASS BK PG VALIDATION
SQ FT NO OF f NO OF / CHECK
License Number Lc Class SIZE STORIES FAMILIES ONE
VALUATION d
Contractor Date DESCRIPTION OF WORK Ca NEW $EI /� OCADDI am exempt under Sec ❑ALTERB&P C for this reasonUS- ��atlE OF � REPAIR ❑ s
Date EXISTIING BLDG /(!! / �/11�iE 8 9 1 7 A
DEMOLSi nature APPLICANT � / TEL #g OWNER BUILDER DECLARATION PRINT /�9G N/ NOFINAL 22I hereby affirm that I am exempt from the Contractor s License �� �� I ° ° 4 Q 5 0
Law for the following reason (Section 7031 5 Business and ADDRESS =
Professions Code) TSENT ° ° ° 4 0 5 0 U
BUILDING C /$s E'Z
w 2 0
Z I as owner of the property or my employees with ADDRESS 4,—8 8
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section [AD
LITY
7044 Business and Professions Code) NG TEL
❑ RACTOR NO
I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec ESS q
hon 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY " - SE BACK YARD HWY UIRED TOTAPROPBALINE WIDTH i
I hereby affirm that there is a construction lending agency for ONT
the performance of the work for which this permit is issued
(Sec 3097 Civ C ) E
Lender s Name ,
LDMA Ref qee$ Permit Fee Lender s Address I certify that I have read this application and state that theIssuance Fee L J LDMA P/C qabove information is correct I agree to comply with all County ,Investigation Fee r
0 ordinances and State laws relating to building construction g Total Fee LDMA Perm tY
and hereby authorize representatives of this County to enter
upo a hove mention�e�d property for inspection urposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
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