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HomeMy Public PortalAbout5342ALESSANDRO AVE_Building (3) 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, Lob. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS I � Certified copy is filed with the county building inspec- BUILDING r- �y tt yy tion department. ADDRESS `ZI 1` 4t� 0 e LOCALITY l-� 0f! Date —Applicant CITY NEAREST 1 pp i ZIP , /? 6 CROSS ST. 11ve. CERTIFICATE OF EXEMPTION FROM WORKERS' //�^•� NO. OF BLDGS. ASSESSOR i COMPENSATION INSURANCE SIZE OF LOT �v' NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. USE ZONE OP hundred dollars ($100)or less.) OWNER i TEL. © ` SPECIAL ys I certify that in the performance-of the work for which this C i1 ,w 0- 1AJ+ 16JINO.' O�'L� CONDITIONS IL permit is issued, I shall not employ any person in any manner ''^) ,//�� ��//��j( �)) DISTRICT GROUP TYPE FIRE PR ESSED BY 0 so-as to become subject to the Workers'Compensation Laws. ADDRESS J " 7 Y'9 Ie,p��11<Ar� 1 •HA2 e CONST. ZOSIE I 4 � � Date Applicant CITY 1 ZIP 9�7 5 STATISTICAL CLASSIFICATION APT. CONDO. NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. V Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS (,Compensation provisions of the Labor Code, you must forth- tff ADDRESS SEWER MAP with comply with such provisions or this permit shall be � deemed revoked. TEL. VALIDATION CONTRACTOR NO. BK. PG, LICENSED CONTRACTORS DECLARATION LIC. f I hereby affirm that I'om licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and y LIC. f Professions Code, and my license is in full force and effect. CITY CLASS �� pop.FT. �}�J NO. OF NO. OF 1 CHECK License Number Lic.Class SIZE a STORIES FAMILIES ONE Contractor Date DESCRIPTION OF WORK NEW $ ❑ I am exempt under Sec. fib " lyv, L�/1r� C ADD ALTER FINAL l B.BP.C. for this reason REPAIR DATE USE OF Date: EXISTING BLDG. r `-Q�, DEMOL ❑ B N L Signature APPLICANT TEL. Y OWNER-BUILDER DECLARATION PRINT) NO. I hereby affirm that I am exempt from the Contractor's License 00.Law for the following reason (Section 7031.5, Business and ADDRESS IPro ssions Code): PRESENT BUILDING c l 7 7 9 R I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ;:!�0 0 0 0 0 the structure is not intended or offered for sole(Section LOCALITY 7044, Business and Professions Code)., MOVING TEL. c I, as owner of the property, am exclusively contracting CONTRACTOR NO. .2'0 o 40.50 0 with licensed contractors to construct the project (Sec- ADDRESS o 0 0 (I 0. �r 0 tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACKFROM EXIST. Q F p 9_g 3 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH , 1 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 1 P.L. Lender's Name P.C. Fee$ Permit Fee Lender's Address .. �� certify that I have read this application and state that the Issuance Fee e ?bove information is correct. I agree to comply with all County Investigation Fee xdinances and State laws relating to building construction, Total Fee ind hereby authorize representatives of this County to enter upon the above-mentioned propertyforinspection purposes. ti .$ S SEE REVERSE FOR EXPLANATORY LANGUAGE Sig re of Applicant or Agent Date .0s