HomeMy Public PortalAbout5048ALESSANDRO AVE_Building (5) r
'WORKERS'COMPENSATION DECLARATION
•raffirm that I have a certificate of consent to self
insuAt,• or a certificate of Workers' Compensation Insurance, •.`A P•P L I CATION f-,O R BUILDING PERMIT
j od•a certified-copy thi,eof (Sec. 3800, Lab. C.) - -
COUNTY,OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company ti
❑ Certified copy is hereby furnished. FOR APPLICANT-TO FILL IN , ADDRESSBUILDIN � �0
ADDRESS J
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS Z S
�0 t
Dote Applicant CITY � ZIP / LOCALITY ,r
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 TRACT BLOCK LOT NO. ASSESSORhundred dollars ($100)or less.) MAP BOOK PAGE PARCEL
TEL. USE Z E MAP
I certify that'in the performance of the work for which this OWNER NO. �$6 NO.
permit is issued, I shall not employ any person in any manner C, SPECIAL
5b
so as to become subject to the Work s'Compensation Laws. ADDRESS CONDITIONS O
U
Date — Applicant CITY _ ZIP
NOTI E TO APPLICANT: If, after making'this CerJicate of ARC ITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
ENGINEER NO. CONST. ZONE ) F- '
Exemption, you should become subject to the Workers' `� �7 U
Compensation provisions of the Labor Code, you must forth- ADDRESSJ�"t/ ✓ W.
with comply with such provisions or this permit shall be �-'
TEL. STATISTICAL CLASSIFI ATION APT. CONDO. U)
deemed revoked. CONTRACTOR NO.
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 and LIC SEWER AQP
Professions Code, and my license is in full force and effect. CITY CLASS BK PGP3 VALIDATION
SQ. FTNO. OF NO. OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW
ADD ❑ $ ,
❑ I am exempt under Sec. X 9 4 6 A
ALTER (� ,y
B.BP.C. for this reason USE OF REPAIR ❑ $ J/ �Q U # o 0.0 e o ,1
Date: EXISTING BLDG. DEMOL ❑ 0 20 'a 6 3
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT NO. DAT ff 0 0 218,6 3 5
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FIN 0 (l,27-88
Professions Code): PRESENT B -
DING
I, as owner of the property, or my employees with ADDR SS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY , 1 ��,,•� - f',
7044, Business and Professions Code). MOVING TEL. 1 i
CONTRACTOR NO.
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- t r ADDRESS f;.
-
'''
tion 7044, Business and Professions Code). �yI`1 , +� •� •
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT �• `°� J,
the performance of the work for which this permit is issued P.L. :.
P P
(Sec. 3097, Civ. C.). SIDE
Lender's Nome P.L.
2 LDMA Ref. # ,A
m P.C. Fee$ Permit Fee J
Lender's Address
I certify that I have read this application and state that the Issuance Fee ( bt�� LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee A7 LDMA Perm. #
o and hereby authorize representatives of this County to enter
m on the above-mentioned erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of licant or Agent Date