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HomeMy Public PortalAbout5510ALESSANDRO AVE_Building d WORKERS'COMPENSATION DECLARATION hereby affirm that' I have certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or o certified copy thereof (Sec. 3800, Lab. C. �. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company El Certified copy is hereby furnished. FOR APPLICANT TO.FILL IN ADDRESS 5_51Z)BUILDING /<l F G� _ D p j1 ` Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS (i fr{/ /n' Date Applicant CITY � V ;! ZIP V LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT 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 J TEL. - O USE NE MAP I certify that in the performance of the work for which this OWNER L NO. NO. permit is issued, I shall not employ any person in any manner c / �' SPECIAL Ot so as to become subject to the Workers'Compensation Laws. ADDRESS J 4 y// A �-� CONDITIONS CITY / V Date 7 Applicant t�r �• �L/ �^ ZIP Flan NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT /GROUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' ENGINEER NO. CONST. ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS Lia. with comply with such provisions or this permit shall be p•, deemed revoked. L STATISTICAL CLASSIFIC TION A CONDO. U) CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER�(v1AP Professions Code, and my license is in full force and effect. CITY CLASS BK J VALIDATION SQ. ra FT. NO. OF NO. OF CHECK PG License Number Lic.Class—' SIZE STORIES FAMILIES ONE ® VALUATION Contractor Date DESCRIPTION OF WORK NEW ADD $ 0Z)0Z)❑ , I am exempt under Sec. ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANTTEL. OWNER-BUILDER DECLARATION PRINT ` i .D NO. FINAL DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS � AL FINAL Pe cions Code): PRESENT By BUILDING 01 3.2 A I, as owner of the property, or my employees with ADDRESS \ wages as their sole compensation,will do the work and ' t e # © o 0 0 0 1 the structure is not intended or offered for sale(Section LOCALITY ' o i� 6 3 7044, Business and Professions Code). MOVING TEL. CONTRACTOR NO. a a 1 4'a 6 3aU t, as owner of the property, am exclusively contracting � •,t `> _ with licensed contractors to construct the project (Sec- ADDRESS o7i1 ,2 tion 7044, Business and Professions Code). �.. REQUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE 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 Lender's Address * P.C. Fee$ Permit Fee (� LDMA Ref. # I certify that I have read this application and state that the Issuance Fee (/LV LDMA P/C# o above information is correct. I agree to comply with all County Investigation Fee 9 ordinances and State lows relating to building construction, Total Fee -�j LDMA Perm. # R and hereby authorize representatives of this County to enter m upon th above-menti ned property for inspection pu pos s. a 7/.! 7 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date