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HomeMy Public PortalAbout5315ALESSANDRO AVE_Building (2) g WORKERS'WMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab C. "fl COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. —Company BUILDING ❑ Certifie py is hereby furnished. FOR APPLICANT TO FILL INADDRESS l ertified copy is filed with the county building inspec- BUILDING tion department. �.f/// ADDRESS S �([ ��U Date V Applicant 1"/'1 CITY ZIP LOCALITY CER FICA E OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST /) COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. u ^�� (This section need not be completed if the permit is for one TRACT BLOCK LO7 NO. ASSESSOR hundred dollars ($100)or less.) TEL. MAP BOOK PAGE PARCEL Le _ SE O I certify that in the performance of the work for which thiOWNER � s NO. UNE MAP ADDRESS NO. _ permit is issued, I shall not employ any person in any manner i' r r- v SPECIAL , so as to become subject to the Workers'Compensation Laws. �/ CONDITIONS O �. V Date Applicant CITY ZIP OR TEL. � NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT iGROUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' ENGINEER NO. r ' CONST. ZONE ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS /.O V W with comply with such provisions or this permit shall be deemed revoked. CONTRACTOR C l^"US(/�it ►^� No S(�3C( STATISTICAL CLASTR •ATION APT.` NDO. z LICENSED CONTRACTORS DECLARATION ` LIC. // CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS f NO. `[ (commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS . 4 SQ. FT. NO.OF NO. OF CHECK BK. PG. VALIDATION Licens ber ` Lic.Class _ ` SIZE STORIES FAMILIES ONE El VALUATION C j DESCRIPTION OF WORK �C — �'C7J NEW ADD ❑ $ am exempt under Sec. r e, d ❑ ALTER B.BP.C. for this reason f S REPAIR s Date: USE OF EXISTING BLDG. t^ DEM^O�L C] Signature APPLICANT(PRINT) C /�`( (� NO, U )I! FINAL 9 9 8A TA OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License DATE//q # oro 0 0 0 1 Low for the following reason (Section 7031.5, Business and ADDRESS b V c FIN Professions Code): PRESENT By o,o 9 6,7 5 ❑ BUILDING I, as owner of the property, or my employees with ADDRESS o,o,- 96751, wages as their sole compensation,will do the work and ' the structure is not intended or offered for sale(Section LOCALITY O 6 O$"8 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- FADDR tion 7044, Business and Professions Code). TOTAL SETBACK UrIn CONSTRUCTION LENDING AGENCY YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Permit Fee G 2 DMA Ref. # Lender's Address c` /, I certify that I have read this application and state that the Issuance Fee ©t 'J V LDMA o above information is correct. I agree to comply with all County n Fee 0 ordinances and State laws relatingto building construction, N Total Fee LD Perm. #' hereby authorize representatives of this County to enter m up th b ve- entioned roperty for insp ct'on purposes. m T/�!�' a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent ate