HomeMy Public PortalAbout5002ALESSANDRO AVE_Building (4) � �
\ ORKERS COMPENSATION DECLARATION �- L!
a or
'o
o,firm that I have a certificate of consent to self V APPLICATION FOR BUILDING PERMIT
insure oa certificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lab C ) �'3 v�� 1 A - COUNTY OF LOS ANGELES BUILDING AND SAFETY
----Policy No 1D y7 OK��ompany - Wry Fu'�yn t t4 � -� � .k
BUILDING
❑ oCertified copy is hereby furnished ' FOR APPLICANT-TO FILL IN ADDRESS _ r i
❑ Certified copy is filed with the county building inspec BUILDING ADDRESS .�' r �.D
tion department "+
_
o CIN YZIF b LOCALITY
Date ~/ro Applicant �L�2.� NO OF BLDGS 1 NEAREST q e
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LO NOW ON LOT CROSS ST
COMPENSATION INSURANCE ' �� ASSESSOR
(This section need not be completed if the permit,is for one TRACT BLOCK MO`f' �'�/ MAP BOOK PAGE PARCEL
hundred dollars ($100) or less ) TEL
v OWNER -NO - USE ZONE MAP '
I certify that in the performance of the work,for which this
' I NO (r/
permit is issued I shall not employ any person in any manner ADDRESS i 1 SPECIAL
CONDITIONS IL
so as to become subject to the Workers Compensation Laws r r OU
CITY ZIP k ,
Date Applicant ARCHITECT 7 �
ENGINEER DISTRICT GROUP TYPE FIRE =SSED O
NOTICE TO APPLICANT If after making this Certificate of / N i CONSTZONEExemption you should become subject to the Workers p s �' w
Compensation provisions of the Labor Code you must forth ADDRESS .�LIJ w 7� a
with comply with such provisions or this permit shall be TEL j¢ STATISTICAL CLASSIFICATION APT CONDO N
deemed revoked _ CONTRACTOR NO Z
LICENSED CONTRACTORS DECLARATION LIC r CLASS NO 24 DWELL UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC j
and Professions Code and my license is in full force and effect _ CITY CLASS BK �pG VALIDATION
SQ FT / NO OF NO OF CHECl�
License Number -� +' t�Jy 6 Lic Class SIZE Y STORIES FAMILIES ONE VALUATION c
+ pUSS&q'5: nKtTo (�`t I"� DESCRIPTION OF WORK NEW
Contractor r\ f Date
El am exempt under Sec ' y a ADD ► a
c
B&P C for this reason ^f ALTER
- � REPAIR D ; _
U OF
Date EXISTING BLDG DEMOL ❑
Signature mo APPLICANT TEL FINAL r
OWNER BUILDER DECLARATION (PRINT) NO +e
DATE
I hereby affirm that I am exempt from the Contractor s License r -
Law for the following reason (Section 7031 5 Business and ADDRESS - FINAL
Professions Code) PRESENT - - By `
❑
BUILDING �/►/w�I as owner of the property or my employees with ADDRESS °•~ , � >I'�v*�R
wages as their sole compensation will do the work and
pp
a
the structure is not intended or offered for sate(Section , - 4700
LOCALITY
7044 Business and Professions Code ) MOVING TEL ^
❑ 1 as owner of the property am exclusively contracting CONTRACTOR NO 1 I 2"
�+s
'- with licensed contractors to construct the project (Sec EADDRE y TM l' I TA. .+G 50
tion 7044 Business and Professions Code ) ti '
TOTAL SETBACK FROM EXIST .6. - -`
` CONSTRUCTION LENDING AGENCY YARD HWY PROP LINE WIDTH ' * r ` - . PECK 2".50
I hereby affirm that there is a construction lending agency for - _�`` 14 - +� y r
.00
the performance of the work for which this permit is issued � � '
(Sec 3097 Civ C ) _ T t/ ee
Lender s Name �� µ, 1 qy 1187
1 - O LDMA Ref # g�
Permit Fee 3875 1 AM 8s19
Lender s Address1 certify that I have read this application and state that the Issuance Fee Q LDMA P/C#
above information is correct I agree to comply with all County ee
R ` ordinances and State lows relating to building construction Total Fee o LDMA Perm.N
a and hereby authorize representatives of this County to enter ,
aupon t above mentioneproperty for inspection purposes
(QQ t SEE REVERSE FOR EXPLANATORY LANGUAGE
1�+ Signature of Applicant or Agent r Date