HomeMy Public PortalAbout5037ALESSANDRO AVE_Building (3) WORKERS COMPENSATION DECLARATION
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ffirm thatrlJiave a certificate of consent to self
`of certified ropy L ,+y thereof(Sec 3800 Lab Compensation Insurance APPLICATION FDR BUILDING PERMIT
COUNTY OF LOS ANGELES' BUILDING AND SAFETY
Policy No Company "
Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING qy�
DADDRESS ft
Certified copy is filed with the county building mspec � BUILDING 3 ��
tion department ADDRESS
a r
Date Applicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE _ SIZE OF LOT NOW ON LOT / CROSS ST
(This section need not be completed if the permit is for one r ASSESSOR
hundred dollars ($100)or less ) TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL
L TEL SE
I certify that in the performance of the work for which this OWNER NO UNE NO r
permit is issued I shall not employ any person in any manner SPECIALt
ADDRESS
so as to become subject to the Work�s�Co(//m///P�en�s/a1tion laws/ CONDITIONS O
4 y`i✓l V I�
CITY ZIP � C.1
Date Applicant ARCHITECT OR TEL
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO DISTRICT GROUP TYPE FIRE PRO SSED BY O
Exemption you"should become subject to the Workers As,, CONST Z E U
Compensation provisions of the Labor Code you must forth ADDRESS �/,t �//�{/ Jt Ld
with comply with such provisions or this permit shall beADDRESS
7 / EL STATISTICAL CLASSIFI ATION APT )CON N
deemed revoked CONTRALTO �/� �C�l/ �G�/ O Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS Z
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO
(commencing with Section 7000)of Division 3 of the Business and Y LIC SEWER MAP
Professions Code and my license is in full force and effect CITY CLASS VALIDATION
SQ FTLItjo NO OFNO OFCHECK BK PG
License Number Lic Class SIZE STORIES FAMILIES ONE 1 7 7 2/i
VALUATION a 70b5
DESCRIPTION OF WORK EW ❑ T I _
Contractor Date y��� ADD $ ® ° ° 1 81.8 8
❑ I am exempt under Sec PD / QU
ALTER ❑ o/� 2 08,24-'87
B 8P C for this reason REPAIR ❑ s ��/j 37
Date USE OF '
EXISTING BLDG I DEMOL ❑
Signature APPLICANT TEL FINAL
OWNER BUILDER DECLARATION PRINT NO
_
I hereby affirm that I am exempt from the Contractor s License DATE
Law for the following reason (Section 7031 5 Business and ADDRESS FINAL
Professions Code) PRESENT By
BUILDING
I as owner of the property or my employees with ADDRESS 1
'a wages as their sole compensation will do the work and 7 9 9 t1 to
the structure is not intended or offered for sale(Section [AD
LITY
7044 Business and Professions Code) ING TELpool # e e o •,° 1
1 as owner of the property am exclusively contracting TRACTOR NO
11K�� with licensed contractors to construct the project (Sec ( ° 2 2 a 0,0
ESS
tion 7044 Business and Professions Code) r 2 2 Q
UIRED TOTAL SETBACK e,o
CONSTRUCTION LENDING AGENCY BACK YARD HWY PROP LINE WIDTH +
I hereby affirm that there is a construction lending agency for ONT 4 Y L4'.� a 7
the performance of the work for which this permit is issued 0 9 2(Sec 3097 Civ C ) E
Lender s Name
77LDMA Ref #
Lender s Address 5-0
Fee$ Permit Fee "! 1 i
I certify that I have read this application and state that the Issuance Fee 1>-V LD.P%C#
o above information is correct I agree to comply with all County Investigation Feeti
0 ordinances and State laws relating to building construction Toral Fee D TDMA Perm #
R and hereby authorize representatives of this County to enter "
up nthhee abbyovee�m/Pnti Property,for inspection purposes
m � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date