HomeMy Public PortalAbout5008ALESSANDRO AVE_Building (2) WORKERS' COMPENSATION DECLARATION
1 hereby affirrri�thclt !have a cq-�icateitf consent to self
(sore, or a certificate of Workers' ompensation Insurance, APPLICATION FOR BUILDING PERMIT
,.or alcertified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
,Policy No. CompanyBUILDING ((��, r( PP�� `l
ElCertified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 50V Al S D�0 y
❑ Certified copy is filed with the county building inspec- BUILDING . 1� i�( w1 j� t) ( JI
C�� C
tion department. ADDRESS ; V}' G �V O V G A(��f ( �q
A .
CITY l" ' LG ZIP I C11 LOCALITY 0 V�WIj WMA ,
Date Applicant NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. L
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL. /
OWNER I No.2� 0 6 USE ONE MAP
I certify that in the performance of the work for which this NO.
h• SPECIAL d
permit is issued, I shall not employ any person in any manner ADDRESS O 0 f+ CONDITIONS
so as to become subject to the Worke s'Comp nsation Laws. OU
/�) CITY S� k ZIP 9111
XDate _ `� Applicant ARCHITECT OR TEL. ISTRICT ROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making t is Certificate of ENGINEER NO. CONST. V NE (��"
Exemption, you should become subject to the Workers' U
Compensation provisions of the Labor Code, you must forth- ADDRESS aa
with comply with such provisions or this permit shall be STATISTICAL CLASSIFICATION APT, I CONDO. N
deemed revoked. CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER P
(commencing with Section 7000)of Division 3 of the Business UC. �`�A
and Professions Code,and my license is in full force and effect. CITY CLASS BK J PGS VALIDATION
SQ. FT. O. OF j NO. OF CHECK
License Number Lic. Class SIZE STORIES 1 FAMILIES ONE
VALUATION ACCT°g
Contractor Date DESCRIPTION OF WORK NEW ❑
s _ O a ► 3307 ITEMS 300°90
❑I am exempt under Sec. Nddp�t/p���b PA. ME
C �Qa �� M ADD I ITEMS
B.&P.C. for this reason 'ti. 044 RA A E VIN REPAIR ❑ a /� 3' 0o0
Date: USE OF TtITAI '��4.P
EXISTING BLDG. DEMOL ❑ CHECK 300°911
Signature APPLICANT C TEL.^�p 44 V 7
g OWNER-BUILDER DECLARATION (PRINT) A �ll.G NO•`0 1016 FINALDATE 0 t CHANGE °0
I hereby affirm that I am exempt from the Contractor's License
ADDRESS
Law for the following reason (Section 7031.5, Business and [�� FINAL )
Professions Code): PRESENT A _ o A Y 000 O q /_lry
WDR
❑ I, as owner of the property, or m employees with BUILDING Ja (1 B VVV —V��1 7�L7/ 7
P P Y YADDRESS �(7i i 1 AM11:01
wages as their sole com ensation,.will do the work and r p A { , -- - ;T 11 t
the structure is not intended or offered for sale(Section LOCALITY 6 C"i If /'T
MOVING TEL. I a
ZU
7044, Business and Professions Code.) ACCT■a
rADDRE
NO. � '` ` '
I, as owner of the property, am exclusively contracting 4.; 3307 3641 50
with licensed contractors to construct the project (Sec- v - V ''"
i ITEMS tion 7044, Business and Professions Code.) t
TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY YARD HWY PROP. LINE WIDTH 364 -50
-°
I hereby affirm that there is a construction lending agency for TOTAL ,�64 m -0
the performance of the work for which this permit is issued r• -� e
(Sec. 3097, Civ. C.). P [;�E�.y; ;64.50
Lender's Name CHANGE °y`I 0 ® Permit Fee v d LDMA Ref. #
Lender's Address15 )
1 certify that I have read this application and state that the Issuance Fee o v - LDMA P/C# 0000-0001 9/26/89
above information is correct. I agree to comply with all Count Investigation Fee :_
8 g P Y Y g 5900 1 AM 11°15
n ordinances and State laws relating to building construction, Total Fee In LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon th above m ntioned pr erty for inspection pur oses.
Z SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature 34 A plicant or Ageint Date