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HomeMy Public PortalAbout4942ALESSANDRO AVE_Building (3) r ;OR;:ERS' COMPENSATION DECLARATION I h;-e'by of;li'rm that I have a cectifi-ate of consent to self insu,a, or a certificate of Workers' Compensation Insurance, APPLICATION FOR 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 ADDRESS Certified copy is filed with the county building inspec- BUILDING //99 JJl tion department. ADDRESS Date Applicant CITY �- }� ZIP r� LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' '7J,� . 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 } . MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TRACT BLOCK LOT NOL].. :/y / _`j_L: TEL. USE ZONE MAP "^ O 1 certify that in the performance of the work for which this OWNER C NO. NO 0 permit is issued, I shall not employ any person in any manner <�'�� ���� ; i jJ�� SPECIAL L3J so as to become subject to the Workers'Compensation Laws. ADDRESS *� CONDITIONS --L ^ / % y CITY I ✓' U/f 5 ZIP Date Applicant-- ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP TYPE FIRE PROCESSED BY Exemption, you should become subject to the Workers' ENGINEER NO. CONST. ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS O CL comply with such provisions or this permit shall be deemed revoked. TEL. STATISTICAL CLASSIFICATION APT, CONDO. 2 CONTRACTOR NO. Ll! LICENSED CONTRACTORS DECLARATION LIC CLASS NO. .' DWELL. UNITS I--. 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. License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK NEW Contractor Date ❑ $ ! ' ADD ❑ ❑ I am exempt under Sec. ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF,EXISTING BLDG. �' >!i L� ' DEMOL ❑ Signature APPLICANT 1 TEL. FlINAL g PRINT jf�r_1. � '_!' f NO. DATE OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License y Law for the following reason (Section 7031.5, Business and ADDRESS �:, FINAL • ` ` ` Professions Code): B © BUILDING Y - , as owner of the property, or my employees with ADDRESS IV IV wages as their sole compensation, will do the work and c the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS > tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK F 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.I. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name LDMA Ref. # a0 P.C. Fee b Permit Fee ' Lender's Address 3 $ I certify that I have read this application and state that the Issuance Fee LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee LDMA Perm. # and hereby authorize representatives of this County to enter m upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date L