HomeMy Public PortalAbout5043ALESSANDRO AVE_Building (5) WORKERS' COMPENSATION DECLARATION
insure,oraa certif carte of Worke sI have rlCompensati nSeInsurancself
, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES v' BUILDING AND SAFETY
Policy No. Company BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
5043 ALESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS5043
, AIESSANDRO AVE- =4plg CITY, GA 94;18()
CITY' 'IT1IPLE CITY CA ZIP 91780 LOCALITY
Date Applicant NO. OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 131 X61 NOW ON LOT NEAREST
1 cRoss ST. LA ROSA DR.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT $ BLOCK LOT NO. MAP BOOK 8590 PAGE Ii((��
A%EL 0DZ
hundred dollars ($100) or less.) TE!c�18 285 USE ZONE MAP
.OWNER WILLIAM CHEIVG - Nd'
I certify that in the performance of.the work for which this No. 1441-1265
permit is issued, I shall not emploSPECIAL
y any person in any manner ADDRESS 5043 ALESSANDRO AVE. R1 CONDITIONS em/'—
so as to become subject to the Workers' Compensation Laws. O
CITY TEMPLE CITY CA zip 91780
Date Applicant ARCHITECT OR TEL. 0
NOTICE.TO APPLICANT: If,.after makingthis Certificate of ENGINEER N/A NO. DISTRICT GROUP TYPE FIRE PROCESSED BY
CONST. ZONE U
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS �� —� w
0-
with
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR NO.
�Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am-licensed under provisions of Chapter 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 1 FAMILIES I ONE
ALL WINDOW VALUATION
DESCRIPTION OF WORK NEW ❑ 00
Contractor Date ORIGINAL PART BUILT IN 1951 . AD
I am exempt under Sec. D ❑ a' v- ' pop.❑ ALTER
B.&P.C. for this reason L' ' REPAIR ❑ $
Date: USE OF
EXISTING BLDG.RESIDENTIAL DEMOL ❑
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT) No285 4952 l
DATE �
I hereby affirm that I am exempt from the Contractor's License 5043 ALESSANDRO AVE. TEMPLE CITY
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL -
Professions Code): PRESENT B
BUILDING
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ---
LOCALITY
the structure is not intended or offered for sale(Section MOVING TEL. ► �',�3�"` � ~
7044,.Business and Professions Code.)
CONTRACTOR NO. �;s' '}
❑ I, as owner of the property, am exclusively contracting 9€.i I HL_- -a `�°='
with licensed contractors to construct The project (Sec-
ADDRESS
tion 7044, Business and Professions Code.)
RE CONSTRUCTION LENDING AGENCY SET BACKK YARD HWY IRED TOTA PREOTBAINEFROM WIDTH '•:!"I�"IN63E a+'I`-
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.). SIDEli�yi t-=ijt t s ;� .
P.L.
Lender's Name _
m O� LDMA Ref. # s
P.C. Fee$ Permit Fee -
3 Lender's Address
0 1 certify that I have read this appli tion and state that the Issuance Fee ; � '/40 LDMA P/C#
8 above information is correct. I agree comply with all County Investigation Fee //
R ordin nces and tate la . r latin to b 'ilding const ction, Total Fee l��• LDMA,Perm. #
a and y u o iz ep e t this County ent
up n he bo - e 'on �9p ty f inspection ses.
ySEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Applicant or Agent Date