HomeMy Public PortalAbout5030ALESSANDRO AVE_Building (5) WOR'ltRS' COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to Self APPLICATION, FOR BUILD_fIVO PERMIT
insure,re, or a certificate of Workers' Compensation Insurance,
or certifi d copy.thereof (Sec. 3800, Lab. C.)
��� J - COUNTY OF LOS ANGELES �; BUILDING AND SAFETY
.P61iY.y No. �QO �Ompony��
Certified copy is hereby furnished. � � FOR APPLICANT TO FILL IN ADDRESS Lf
Certified copy is filed with the county building inspec- BUILDING A�
Tion depart ent. ADDRESS' /Etr v �f
�/ ��� �}� CITY ZIP LOCALITY
Date 7 Applicant/ NO. OF BLDGS.
CERTI CATE OF EXEMPTION FROM WORKERS' SIZE OF. LOT NOW ON LOT NEAREST
CROSS ST.
COMPENSATION INSURANCE ASSESSOR C f 1t /}
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK f J 7 e AGE v� PARCELo'1:0-0
hundred dollars ($100) or less.) }M —r TEL.
OWNER � K'/ NO. USE ZONE
I'certify that in the performance.of the work for which this SPECIAL >-
permit is issued, I shall not employ,any person in.any manner ADDRESS ' CONDITIONS 0-
so as to become subject to the Workers' Compensation Laws. 0
CITY ZIP
Date Applicant ARCHITECT OR TEL. - DISTRICT GROUP TYPE FIRE PROCESSED BY 0
NOTICE TO APPLICANT:. If, after making.this Certificate of ENGINEER NO.
CONST. ZONE
Exemption, you should become. -subject to the. Workers'
w
Compensation provisions of the Labor Code, you must forth- ADDRESS a-
with comply with.such provisions or this permit shall be r TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
CONTRACTOR /�� NO. ��
deemed revoked. ��
LICENSED CONTRACTORS DECLARATION. ADDRESS ` Na CLASS NO. DWELL.,UNITS
I hereby affirm that I am licensed under provisions,of Chapter 9 / SEWER MAP
(commencing with Section 7000)of Division 3 of the BusinessCITY a CLASS T f�
and Professions Code,and my license is in full force and effect. BK.-.-7' PG c-'C, VALIDATION
/ SQ. FT. NO. OF NO. OF CHECK
License Number (v Lic. Class SIZE J STORIES FAMILIES ONE
/(, GS oA/i 2 VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑ $
/in•�
+ ADD (1U pop .
❑I am exempt under Sec.
ALTER E3BAP.C. for this•reason ' REPAIR El $
DUSE OF
Date: +DGDEMOL ❑
EXISTING BL . L /
Signature APPLICANT TEL. / FINAL
OWNER-BUILDER DECLARATION (PRINT) NO. (Q B
DATE
I hereby affirm that l,am exempt from the Contractor's License 74
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code), PRESENT By _
BUILDING
ElI, as owner of the.property, or my employees with ADDRESS //
wages as their sole compensation,will do the work and .9
the structure is not intended or offered for sale(Section LOCALITY --
7044, Business and Professions Code.) MOVING TEL.
CONTRACTOR❑ NO.I, as owner of the property, am exclusively-contracting
with licensed contractors to construct the project (Sec- ADDRESS D`6`1
_
tion 7044, Business.and Professions Code.) u: ; -
REQUIRED TOTAL SETBACK FROM EXIST. {.•I`�_ti_€.`
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
NUtl.;
I hereby affirm that there is a construction lending agency for FRONT i
-. ii):{,3 �._..-
the performance of the work for which this permit is issued P.L.
,(Sec. 3097, Civ. C.).- SIDE
P.L.
Lender's'Name
,S LDMA Ref. # t 1
P.C. Fee$ v< �• Permit Fee (O- �`� _t R.
3 Lender's Address
0 1 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 Investigatidn Fee C
8 ordinances and State laws relating to building construction, I Total Fee 2 L LDMA Perm. #
a and hereby authorize rep sentatives of this County to enter
upon The above- d property for inspectio urpo s.
�� ��,P� SEE REVERSE FOR EXPLANATORY LANGUAGE
10
at
Signure of A scant r gent Date