HomeMy Public PortalAbout5514ALESSANDRO AVE_Building (2) WORKEVS COMPENSATION DECLARATION v
a
uP athat I hove'a certificate of consent self
ure or a certificate of Workers Compensation Insurance " APPLICATION F®R B U I L D k N G PERMIT
F- .Or
a certified copy thereof (Sec 3800 Lab C ) COUNTY OFAOS ANGELES BUILDING,AN SAFETY,
icy No Company `Certified copy is hereby furnished r FOR APPLICANT TO FILL IN BUILDING �S� C
ADDRESS
❑ Certified copy is filed with the county building inspec BUILDING -
• hon department ADDRESS �+ n�i / ✓ 4 '.
114
4 } t p A a
Date Applicant CITY r; (/1 ZIP I LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT l NOW ON LOT CROSS ST
(This section need not be completed if the permit is for one _ ASSESSOR F _
hundred dollars($100)or,less ) TRACT BLOCK LOT NO MAP BOOK P E PARCEL
EL
OWNER
USE ZONE MAP '
I certify that in the performance of the work for which this 1 NO NO
permit is issued I shall not employ any person in any manner C SPECIAL • _ t
ADDRESS ( Lam,. N 1 (IN ' CONDITIONS +
so aslto become su ecX�t to the Workers o pens ion Laws � U
Date i A iicant _ CITY -! biA l i� ZIP
pp ARCHITECT OR TEL DISTRICT GROJPTYPE FIRE PROCESSED BY
-* NOTICE TO APPLI ANT If after a this Certificate of �� 0
g ENGINEER NO o ^� CON
NST ZONE L1J
r Exemption you should become subject ato the Workers
Compensation provisions of The Labor,Code you must forth r w v
ADDRESS
with comply with such provisions or this permit shall be zr n TEL STATISTICAL CLASSIFICATION • APT CON C/)
deemed revoked , CONTRACTOR clv NO Z
LICENSED CONTRACTORS DECLARATION " — LIC , CLASS NO �- DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 91 ADDRESS 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 CLASS +, VALIDATION
1 a I n . SQ FTI&,4 NO OF NO OF CHECK BK PG
License Number , Lic Class SIZE L8% TORIES FAMILIES ONE
u T�f1 ALUATION�1
Contractor Date
DESCRIPTION OF WORK 'J rJ/��(JI�+ AD ❑ s / 7r6�
1 am exempt under Sec ' f� {�/� 1�/ n� J /� l t
i s ALTER ❑ —40787A
REPAIR o • o • m
B 8P C for this reason Date w ❑ $
USE OF DEMOL ❑ ' - 15300
1
EXISTING BLDG
" Si nature APPLICANT TEL �J�+� r+i , ✓� W
Signature PRINT �i NO Z; /�d3�� FINAL
OWNER BUILDER DECLARATION
I he eby affirm that I am exempt from the Contractor s License DAT u d� 5 a O O Y ,
for the following reason (Section 7031 5 Business and ADDRESS FINAL • Q 9 2 8`-88
ro sstons Code) < - By
BUILDING
I ,as owner of the property or my employees with ADDRESS # f c
wages as their sole compensation will do the work and ,
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code) MOVING 3 TEL
CONTRACTOR NO
I as owner of the property am exclusively contracting +
with-licensed contractors to construct the project (Sec c
tion 7044 Business and Professions Code) ADDRESS
REQUIRED TOTAL SETBACK `
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTHZ
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
PL +
Lender s Name ~
i LDMA RQf #
P C Fee$ - u Permit Fee
Lender s Address p "
I certify that I have read this application and state that the Issuance Fee ( LDMA P/C M t
above information is correct I agree to comply with all County Investigation Fee
S ordinances and State laws relating to building construction 4
}and here authorize re resentatives of this County to enter Total Fee LDMA Perm q F r
`m upon th b e m ti dWrty for inspects r s s
m �
SEE REVERSE FOR EXPLANATORY LANGUAGE
a t
Signature of Applicant or Agent Date -
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