HomeMy Public PortalAbout5043ALESSANDRO AVE_Building (4) WORKERS' COMPENSATION DECLARATION I
hereby affirm that I have a certificate of consent to self APPLICATION F R:-'B U I L D I N G PERMIT
insure, ora certificate of Workers' Compensation Insurance, t
br a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING� 0;/n
PY Y ADDRESS) /�L.s
❑ Certified copy is filed with the county building inspec- BUILDING F o
tion department. ADDRESS V �� 0 Cfi' L l
CITY —' ,�. LI - ZIP (/ LOCALITY
Dare Applicant /' O. OF BLDGS.
CERTIFICATE OF EXEMPTION FROM.WORKERS' SIZE OF LOT (Q NOW ON LOT / NEAREST
CROSS ST. �)( '
COMPENSATION INSURANCE �pyf� ASSESSOR v
(This section need not be completed if the permit is for one TRACT' (� BLOCK LOT NO.e/v MAP BOOK PAGEF�Z YJ PARCEL Q
hundred dollars ($100) or less.) OWNER 4' NO �� USE ZONE MAP
1 certify that in the performance of the work for which this SPE
permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL
so as to become subject toCONDITIONS
the Workers' Compensation Laws. d O
CITY ZIP
Date Applicant ARCHITECT OR TEL. �
NOTICE TO APPLICANT: If, after.making this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIREkPROCESSED BY
Exemption, you should become subject To The Workers' a CONST. Z NE U
Compensation provisions of The Labor Code, you must forth- ADDRESS®� J /GLG
with comply with such provisions or this permit shall be �� NO NO.
CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR -� / DWELL. UNITS
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
LIC. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business ,
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
/a ces e VALUATION t :€_'c
Contractor Date ppDE��SCRIPTION OF WORK i NEW ❑ $ ��—
v-1 D Oh �� • ADD ❑ ► _._ ..ti..,.__
❑1 am exempt under Sec. �e IS .t r
P ALTER A la LJ
B.&P.C. for This reason �n � --
USE OF V� REPAIR $
Date:
t_ ;i t=• _r •
EXISTING BLDG. DEMOL ❑ _
APPLICANT .-'7 st•^ L "`
Signature a TEL /(�� L .'t"�'•_•a'• _
OWNER-BUILDER DECLARATION
(PRINT) FINA
) C N DATE 4( —ll/ i: sti 1sTs� i li_i
I hereby affirm that I am exempt from the Contractor's License r -
Low for the following reason (Section 7031.5, Business and ADDRES'S O FINAL . -
Profpssions Code): PRESENT By
L�6�( BUILDING €{i lIr-?ii,_F^ 5,'
I, as owner of the property, or my employees with ADDRESS -, ;yam
wages as their sole compensation,will do the work and ,�m�l�`Y� �J�� r�j� h(� t j' 3 - _
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL.
I, as owner of The property, am exclusively contracting
CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.)
CONSTRUCTION LENDING AGENCY SETT BACKK YARD HWY TOTAL SETBACK ]EXWIDTH
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
P.C. Fee$ Permit Fee ty_'!�'117 LDMA Ref. #
Lender's.Address 1 certify that I have read this application and state that the Issuance Fee 7LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
ordin ces and STaTe laws re ng to building construction, Total Fee GLDMA Perm. #
a and r y a horize r p set t, es of th' Co ty to enter
aup t ab e d ' rty f r in ion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of licantW Agent Date