HomeMy Public PortalAbout5329ALESSANDRO AVE_Building (2) WORKERS'COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
t�/T Sf t� l COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N�LLy—Company / lL� BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 5 2-
❑ Certified copy is filed with the county building inspec- BUILDING ��
tion department. ADDRESS
Date '' Applicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS NEAREST
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one Qr ASSESSOR If
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. USE NE MAP
I certify that in the performance of the work for which this OWNER NO. I NO.
permit is issued, I shall not employ any person in any manner o SPECIALt,
so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS 01
CITY ZIP U"
Dote Applicant
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
ENGINEER NO. CONST. ZONE 1•-•`
Exemption, you should become subject to the Workers' U`
Compensation provisions of the Labor Code, you must forth- ADDRESS LaJ
with comply with such provisions or this permit shall be TEL. 0 ATI TICAL CLASSIFICATION APT. I CO N
deemed revoked. CONTRACTOR O.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. y/ DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �' /^ r 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 �� Z CLASS BK PG VALIDATION
SQ. FT. NO.OF NO. OF CHECK
License Number Y2.j Lic.Class SIZE STORIES FAMILIES ONE
./y''/','0 ❑ VALUATION
Contractor!1/I /�� /!L4 Date wZ/ DESCRIPTION OF WORK NEW $
ADD ❑ (� pill.I am exempt under Sec. �— � _22'�`�_{ ALTER ❑ 2 0 7 3,5 A
B.BP.C. for this reason 7-0 �• d�• / REPAIR $
Date: USE OF # o 'o.0 ° o J
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL. ,{ FINAL
OWNER-BUILDER DECLARATION PRINT NO. Q DATE
I hereby affirm that I om exempt from the Contractor's License n'L 6 8,63 v
Law for the following reason (Section 7031.5, Business and ADDRESS ( /Tl 2 FIN
Professions Code): PRESENT BY o9.22-88
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY o
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- ADDRESS
tion 7044, Business and Professions Code). ,.'
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAL SETBACK
NE WIDTH
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.
Lender's Name
m P:C. Fee$ Permit fee ' ✓� LDMA Ref. #
Lender's Address
3 I certify that I have read this application and state that the
$ Y pp Issuance Fee 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, `
R and hereby authorize representatives of this County to enter Total Fee ICMA.Perm. #.
f
upon thab-�ov -mentio ed property for inspection purposes.
a �� f
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote