HomeMy Public PortalAbout5043ALESSANDRO AVE_Building (6) WORKERS' COMPENSATION DECLARATION
I.:nereb5 yaffir n that'I have'a--certificate of consent to self
insure, or a certificate of Workers' Cbmpensation insurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING ^Tq 0
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS VV 'roc-l�•+'
❑ Certified copy is filed with the county building inspec- BUILDING 50
tion department. ADDRESS
Date Applicant CITY L. 1 ZIP LOCALITY
N . OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST
COMPENSATION INSURANCE ASSESSOR
(This section need.not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK P PARCEL
hundred dollars ($100) or less.) T L
OWNER( , r USE ZONE MAP
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any manner ADDRESS ? D — SPECIAL CONDITIONS
CONDITIONS
so as to become subject to the Workers'Compensation Laws. p
'CITY — (i ZIP U
Applicant ARCHITECT OR TEL.
O APPLICANT: If, after making,this Certificate of ENGINEER , NO. DISTR�Iyy GROUP ITYPIO
FIR O SED B
*xemption, you should become subject to the Workers' wompensation provisions of the Labor Code, you must forth- ADDRESS I tZ
with comply with such provisions or this permit shall be q TEL. /—r S ATISTICAL CLA FIC TION AP . CONDO. Z
deemed revoked. CONTRACTOR A' 3S► —
LICENSED CONTRACTORS DECLARATION LIC. t> CLASS NO. DWELL. UNITS
sLI�'i
I hereby affirm that I am licensed under provisions of Chapter9 ADDRESS O.NCSEWER MAPLI
(commencing with Section 7000)of D'i'vision 3 of the Business
SS
and Professions Code,and my license.is in full force and effect. CIN � � BK. PG. i11v VALIDATION
SQ. FT� OF NO. OF CHECK tlf: •i°t 9
License Number Lic. Class SIZE STORIES FAMILIES ONE
VALUATION 3,707 314°9
Contractor Date DESCRIPTION OF WORK NEW. ❑ $ ® / b Q pop.
ITEMS
❑1 am exempt under Sec. ' Z e ADD t ! 't 3
ALTER TOTAL,. 3�� m �,'J�
B.&P.C. for this reason 1 REPAIR ❑ E u t tt.� ii
Date: USE OF DEMOL ❑ CHECK 314°?3
EXISTING BLDG. &-p egsT It CHANGE i
Signature / APPLICANT TEL. CHANGE °O l
OWN -BUILDER DE RATr1.5Business
(PRINT) f L L C11f f N NO. z �7�' DA EFINAL �•
I hereby affirm that I am exempt from ther's License G� /�, r -1 -1 -1811,89
:;.�-
Law for the following reason (Sectio and ADDRESS Lf3 `J�1/V��0 FINAL �) I��— i-) 1.:� v ='�
Professions Code): PRESENT By 9;44
❑ I, as owner of the propert or m employees with BUILDING
P P YADDRESS •` •
wages as their sole compensation,will do the work and - 11 `1=�?
the structure is not intended or offered for sale(Section LOCALITY , � w
3.
7044, Business and Professions Code.) MOVING TEL. '1 I E:
® I, as owner of the property, am exclusive) contractingCONTRACTOR NO. TOTAL
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code.) ADDRESS CHECK. +�?,`ij
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH CHANGE
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. (?{lief—I�t L i ce'% 7 f 11
Lender's Name. 7
LDMA Ref. # _: ,5f - 1 Ar l
P.C.. Fee$ IA . Permit Fee
Lender's Address pop. ,
0 1 certify that I have read this application and state that the Issuance Fee i 00 LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee 0
6 ordinances and State laws relating to building construction, Total Fee V LDMA Perm. #
a and hereby authorize representatives of this County to enter
upo In rove)nen'on d property for inspection purposes.
• SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature o Applicant or Agent Date