HomeMy Public PortalAbout5037ALESSANDRO AVE_Building WORKERS' COMPENSATION DECLARATION ,
hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, cp,L a certificate of Workers' Compensation Insurance,
tar a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 62-s—s �=• 0/e0�!/�.
❑ Certified cop I y is filed with the county g inspec- BUILDING
tion department. pec- ADDRESS
Date Applicant CITYZIP / LOCALITY !T /_4
NO. OF BLDGS. NEAREST /J �
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. G/4
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT' BLOCK LOT NO. MAP BOOK gs-c/0 PAGE Q Z -PARCEL 00
hundred dollars ($100) or less.) TEL. USE ZONE MAP 7
OWNER NO. NO. rZ
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL d
CONDITIONS
so as to become subject to the Workers' Compensation Laws. 0
CITYMISeE Ozy ZIP
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PRqQESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE 0
Exemption, you should become subject to the Workers'
Compensatioprovisions of the Labor Code, you must forth- ADDRESS L% v _�- C a-
with comply with such provisions or this permit shall be a L STATISTICAL CLASSIFICATION APT. I CONDO. Z
deemed revoked. CONTRACTOR —
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK NEW 1900
ADD ►
Contractor Date /
� ADD
❑I am exempt under Sec. ❑
ALTER
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF ,y
EXISTING BLDG. IV�li^/�1�LY DEMOL ❑
Si nature APPLICANT TEL.
g OWNER-BUILDER DECLARATION (PRINT) ,y1 17j� NOZrS S_ FINAI
DATE
I hereby affirm that I am exempt from the Contractor's License _:S �.� �9NOJe0� .
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL _
Professions Code): PRESENT By A• "''
BUILDING
❑ I, as owner of the property, or my employees with ADDRESS ,f--•
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.
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- ADDRESS 1 ..'•-
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.
LDMA Ref. #
P.C. Fee$ Permit Fee
Lender's Address ►
,0 1 certify that I have read this application and state that the Issuance Fee 2 LDMA P/C#
8 above information is correct. I agree to comply with al County Investigation Fee. r "d
'o ordinances and State laws relating to building construction, Total Fee �7 LDMA Perm. #
Q
and/hereby authorize representatives/If this County to enter
o up e a v do roperty or inspection purposes.
�' SEE REVERSE FOR EXPLANATORY LANGUAGE
ISignature of Applicant or Agent Date