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HomeMy Public PortalAbout5342ALESSANDRO AVE_Building tl r�, WORKERS' COMPENSATION DECLARATION ' ialuafcertcarI have a certificate of consent te of Worke s' Compensat on Insuran el re' 6racertificate f APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NO.0 &Y© 7 , Company fi•Q BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL INA ADDRESS ,rj'j frQf dQ9 Aw, � X Certified copy is filed with the county building inspec- BUILDING tion (department. ADDRESS �S Q yam, (,�(i Date—1 ` Applicant CITY e.,4, ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM ORKERS' I NO. OF BLDGS. n NEAREST COMPENSATION INSURA CE SIZE OF LOT -Z)vx NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars ($100) or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL �� n I certify that in the performance of the work for which this OWNER G� U NO.TEL. USE ZONE MAPNO. permit is issued, I shall not employ any person in any manner SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS �312ORo AC• CONDITIONS Dote Applicant CITY VWLC C A- ZIP NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT CMUP TYPE FIRE PROCESSED BY Exemption, you should become subject to the Workers' ENGINEER NO. �` / � CONST.,/ ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS /1� U �F/ with comply with such provisions or this permit shall be CONTRACTOR 14W_M NOTEL.. /* deemed revoked. 1X� STATISTICAL CLASSIFI ATION APT. NDO. LICENSED CONTRACTORS DECLARATION LIC 3 CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 0,1 1{' L.4 . 6444 e'. NO. (commencing with Section 7000)of Division 3 of the Business and ILIC QQ SEWER MAP Professions Code, and my license is in full force and effect. CITY WE5 (O /NA CLASS ID'� BK. PG VALIDATION il�r•�p2 q SQ. FT. NO. OF NO. OF CHECKp. License Number— JG J / Lic.Class SIZE STORIES FAMILIES ONE 0 ❑ VALUATION Contractor Date DESCRIPTION OF AO ID !L QCD NEW 2 /'l�DITD ADD $ � "` , O ❑ I am exempt der Sec. 4 ALTER W B.BP.C. for this reason REPAIR ❑ $ tom' Date: USE OF EXISTING BLDG. Id�JGf' DEMOL ❑ Z Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) O"1.Oe aakr NO. D- DATE I hereby affirm that I am exempt from the Contractor's License �p war Law for the following reason (Section 7031.5, Business and ADDRESS ;U qq LV, Grni *4AVE COV1,44 F Professions Code): PRE EN Y i ❑ I, as owner of the property, or my employees with BUILDINGADDRESS X wages as their sole compensation,will do the work and ' ACCT. the structure is not intended or offered for sale(Section LOCALITY vK- 7044, Business and Professions Code). MOVING TEL. ❑ CONTRACTOR NO.I, as owner of the property, am exclusively contracting 1 ITEMS EMJ with licensed contractors to construct the project (Sec- ADDRESS Q tion 7044, Business and Professions Code). TOTAL 199 ® '1.-pa—+' REQUIRED TOTAL SETBACK FROM CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH i ;HEC 1y•�e 85J 1 hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this CHANGE t�Id p permit is issued P.L. ,= (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name _ _ LDMA Ref. # j ;{ 7 77 OOCICI-0001� Z Lender's Address P.C. Fee$ Permit Fee r / I ri 3 AM g I certify that I have read this application and state that the Issuance Fee S LDMA P/C apool �� oabove information is correct. I agree to comply with all County Investigation Fee o ordinances and State laws relating to building construction, dTotal Fee LDMA Perm. # and hereby authorize representatives of this County to enter m upon the ab - tione p operty for inspection purposes. Z SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of App a or Agent Date