HomeMy Public PortalAbout5329ALESSANDRO AVE_Building (3) • ,,WORKERS' COMPENSATION DECLARATION
insure,herebyaffirm
acertificate afrte of'Workers' Compensation I have a certificate of eInsuran e, APPLICATION FOR BUILDING PERMIT
or a certified cop thereof (Sec. 3800, Lab. c.)yr rs COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS o�- �y
IF �' ZIP LOCALITY
Date '•A Applicants-2--i-Vi, CITY NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WO ERS' SIZE OF LOT p NOW ON LOT J CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRAC BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL:
OWNER ��,��J N USE ZONE MAP
I certify that in the performance of the work for this NO.
t�J 'Jl /�� �j r ' SPECIAL
i permit is issued, I shall not employ any perso any manner ADDRESS cam[ CONDITIONS O
so as to become subject to the Workers' mpensation Laws. V
i CITY � ,,, ZIP �
Date Applic ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY Q
NOTICE TO APPLICANT• after making this Certificate of ENGINEER �c�e NO. CONST. ZONE H-
t Exemption, you s d become subject to the Workers' V
i Compensatio ovisions of the Labor Code, you must for
ADDRESS D` 3 a-
o_
with c with such provisions or this �'J/fir^/ STATISTICAL CLASSIFICATION APT. CONDO. N
y p permit shall be TEL. Z
ed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION . � � • �l�' LIC. CLASS NO. �/ DWELL. UNITS
-
I herebyaffirm that I am licensed under rovisions of Chapter 9 ADDRES NO. ui�
p p � LIC. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business CITY /t°�j�®r CLASS
and Professions Code;.and my license is in full force and effect. BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
f License Number �� Lic. Class SIZE 4 STORIES FAMILIES ONE
VALUATION a0
Contractor Date DESCRIPTION OF WORK NEW $ /' r �s
❑I am exempt under Sec. /`�/�i`L�`i ADD �Q G1L� ,
ALTER ❑
B.BP.C. for this reason �G7L� /�✓ REPAIR ❑ $
USE OF ) j
Date: EXISTING BLDG. j/� + �i L DEMOL ❑
Signature APPLICANT, TEL. r,> / � FINAL
OWNER-BUILDER DECLARATION (PRINT) % fNO. DATE _
I hereby affirm that I am exempt from the Con ctor's License ADDRESS �/ �R �- ����1
Law for the following reason (Section 703 .5, Business and FINAL --
Professions Code): PRESENT By
BUILDING
❑ I, as owner of the.property, r my employees with ADDRESS -+--t-
wages as their sole compen tion,will do the work and N1111,
the structure is not intend or offered for sale(Section LOCALITY
7044, Business and Pro ssions'Code.) MOVING TEL. i
CONTRACTOR NO.
I, as owner of the p petty, am exclusively contracting �.;, :'��;�
with licensed co actors to construct the project (Sec- ADDRESS
tion 7044, Busi ss and Professions Code.) `„:!
.REQUIRED TOTALS FROM JWXID"TTH
CO RUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE
T .•:�
I hereby affirm at there is*a construction lending agency tor FRONT t
the perform ce of the work for which this permit is issued P.L. f
(Sec. 3097, Civ. C.). SIDE =''``L 19- r r
Lender's Name
'r'y..i.
LDMA Ref. #P.C. Fee$ �/ ' Permit Fee Lender's Address
I certify that I have read this application and state that The Issuance Fee ✓ LDMA PiC#above information is correct. I agree to comply with all County Investigation Fee i l=^t_('}_ttCj ) r:,•a ;_;.:
ordinances and State laws relating to building construction, Total Fee LDMA Perm. # `
and hereby authorize representati es of this County to enter -s_;rt _ ��)
upon4ignature7of
ve- ton4rgenrt
jnspection purposes. 3�r�”
a
� l SEE REVERSE FOR EXPLANATORY LANGUAGE
ApplicaDate