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HomeMy Public PortalAbout5315ALESSANDRO AVE_Building (3) WORK' COMPENSATION DECLARATION I hby affirm that I have a certificate of consent to self ere nsure. Or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT `or a certifie ciioy thereof (Sec. 3800, ab. C.) COUNTY OF LOS ANGELES BUILDING AND SAF TY Policy No. Company 2 / ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ) /S ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 5�t� A�tSSaN ✓� Date Applicant CITY ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT ��6D SNOW ON LOT CROSS ST. (This section need not be completed if the permit is for one �J ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO/07111MAP BOOK AGE PARCEL 1 TEL. .�p�. USE NE MAP OWNER �"{ C2 TNO EL. �� � I certify that in the performance of the work for which this NO, permit is issued, I shall not employ any person in any manner SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS ✓n e a.S �•� CONDITIONS O Date Applicant „�~ CITY ZIP ARCHITECT OR TEL. DISTRICT G UP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ' Cotes CONST. ZONE U Exemption, you should become subject to the Workers' ENGINEER QI �t /r / NO. �/ / / // Compensation provisions of the Labor Code, you must forth- ADDRESS �Gv tea^ (�t6w#V Dplid' V61 ��/v ` W. with comply with such provisions or this permit shall be TEL. � deemed revoked. , Ams M_e d" L' �7 STATISTICAL CLASSIFICATION APT. NDO. fn CONTRACTOR NO. J LICENSED CONTRACTORS DECLARATIONLIC• �' CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �S �� NO '60 Qv"' (commencing with Section 7000)of Division 3 of the Business andLIC SEWER MAP Professions Code, and my license is in full force and effect. CITY 6-q / '! CLASS 'E3''1 BK PG VALIDATION x�vSQ. FT. NO. OF NO. OF CHECK License v © Lie.Class `� SIZE STORIES FAMILIES ONE 7' NEW ❑ VALUATION do Contra to pate DESCRIPTION OF WORK ADD (/$ /T'-i� ❑ I am exempt under Sec. ALTER B.BP.C. for this reason rr9CD REPAIR ❑ $ Dote: USE OF DEMOL EXISTING BLDG. ❑ Signature APPLICANT �` TEL• FINAL OWNER-BUILDER DECLARATION PRINT M NO. 5 DAT I hereby affirm that I am exempt from the Contractor's License ADDRESS ���U t�S A ( l rV S' `"CGC��Zi Law for the following reason (Section 7031.5, Business and FIN Professions Code): PRESENTBY9 3 4.1 A BUILDING ❑ I, as owner of the property, or my employees with ADDRESS # 0.0 0 0 0-1 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ' o o9&75 7044, Business and Professions Code). MOVING TEL. , ❑ CONTRACTOR NO. I, as owner of the property, am exclusively contracting o o --9675Z with licensed contractors to construct the project (Sec- ADDRESS a , tion 7044, Business and Professions Code). 0 7'� 8 CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY EQUIRED TOTAPROPLIINE WIDTH ' `` t 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 Lender's Name ` LDMA Ref. m P.C. Fee$ Permit Fee J Lender's Address 3 - F i? I certif t I have read this application and state that the Issuance Fee V i.) (f kLD P/C.k -. obo i or is car I. I agree to comply with all County Investigation Fee 0 or man nd t s relating to building construction, Total Fee LDMA Perm. # a d u o resentatives of this County to enter i p'on ove- d property for inspection purpos u- '7 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Date