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HomeMy Public PortalAbout5031ALESSANDRO AVE_Building (4) �. WORKERS`COMPENSATION DECLARATION l; I. hereby raffirm that I have r certificate of consent to self APPLICATION FOR BUILDING' �tM I T insure, or a certificate of Workers' Compensation Insurance, �y or a certified copy thereof (Sec. 3800, Lab. C.) _ r COUNTY OF LOS ANGELES r= 'BUILDING AND SAF&TY Policy No. Company ^� JAD ILDING I T'-�SA DV ❑ Certified copy is her furnished. FOR APPLICANT TO FILL INDRESS 1.-L ❑ Certified copy is filed with the county building inspec- BUILDING Tion department. ADDRESS © AL( ��� Date Applicant CITY T� �L�� ZIPCALITY NO. OF BLDGS. AREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOTOSS ST. COMPENSATION INSURANCE SESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. E ZONE MAPOWNER f2 N NO.I certify that in the performance'of the work for which this n NO.permit is issued, I shall not employ any person in any manner ADDRESS 1 AL-•.�S SAN p �/_ SPECIAL }t CONDITIONS a". so as to become subject To the Work rs'Compensation Laws. O CITY ZIP U Date _ Applicant ARCHITECT OR TEL. 13� DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, aft making this ertificate of ENGINEER NO. - � Exemption, you should bet bo a subject to .the WorkersU ® � -3 CONST. W y / ZONE U Compensation provisions of the Lar Code, you must forth-- ADDRESS (/ ✓ !rte with comply with such provisions or this permit shall be 0lw(F0.2N 'ST TEL./�� CL (7 G STATISTICAL CLASSIFICATION APT. CONDO. deemed,revoked. CONTRACTOR ry NO 3'T Z_ LICENSED CONTRACTORS DECLARATION -� LIC. p� Q CLASS NO. �/ DWELL. UNITS 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS � _1-SGQ A-, NO.S� l D 3 LIC. SEWER MAP (commencing with Section 7000)of Division 3 of the Business q� and Professions Code,and my license is in full force and effect. CITY eG Q% JCfz!� CLASS J BK PG. VALIDATION �. SQ. FT.`i�� NO. OF NO. OF CHECK License Number {IV�J Lic. Class �- SIZE 1 FAMILIES ONE ,/� n6'[ DESCRIPTION OF WORK S'`FV� �CjGic� NEW ❑ VALUATION Contractor Date �` $ � ADD , ❑I am xempt under Sec. T' ALTER ❑ B.&P.C. for this reasonREPAIR ❑ Date: USE OF EXISTING BLDG. DE MOL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) ,Q�1ti5' Go�.y2va1C-$ 'NO. —OH3 I hereby affirm that 1'am exempt from the Contractor's Licenset DATE Law for the following reason (Section 7031.5, Business and ADDRESS P Z7��yy 1 r4 ESC �1; TCT t+1U1� FINAL Professions Code): PRESENT BY BUILDING ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY - 7044,-Business and Professions Code.) MOVING TEL. CONTRACTOR NO. 1"" ❑' I, as owner of the property, am exclusively contracting with licensed contractors,to construct the project(Sec- M € ADDRESS tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. -- CONSTRUCTION LENDING AGENCY SET BACK YARD 'HWY 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.L. (Sec. 3097, Civ. C.). SIDE P L. Lender's Name i_t_' !: 1 ;• J a ?_ {jll m LDMA Ref. # s t.a fi'{. •f P.C. Fee $ Permit fee �6 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 Investigation Fee 8 ordinances and State laws relating to building construction, Total Fee C:00 0' LDMA Perm.•# a and hereby authorize representatives of this County to enter r' 1 upon th ab ve-me tinned property'for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Appfcont or Agent Date