HomeMy Public PortalAbout5525ALESSANDRO AVE_Building (2) WORKERS'lJMPENSATION DECLARATION
' I sure, y>> cier the I have r certificate of consent to self APPLICATION FOR BUILDING PERMIT
`'"insure, or a certifrbte of Workers' Compensation Insurance,
or a certified cop thereof (Sec. 3800, Dab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑
BUILDING
Certifiod copy is hereby furnished. FOR APPLICANT TO FILL IN
❑ _ ADDRESS
Cert��ed copy is filed with the county b ilding inspec- BUILDING ,/
tior department. ADDRESS � d(.i
Date1� Applican ZIP
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO, OF SIZE OF LOT �v NOW ON LOTS ROSS ST. rP p•QQ{f!� �[0aP G ru@ 9/
COMPENSATION INSURANCE
(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
4eV16 4r1W TEL t USE ZONE MAP
I certify that in the performance of the work for which this OWNER NO. i71 NO. _
permit is issued, I shall not employ any person in any manner ADDRESS / SPECIALt
so as to become subject to the Workers'Compensation Laws. CONDITIONS0.
U
Date Applicant CITY ZIP �
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 L- NO: CONS ZONE
E U
Compensation provisions of the Labor Code, you must forth- ADDRESS ;5' `J J�J
with comply with such provisions or this permit shall be CL
deemed revoked. � TEL STATISTICAL CLASSIFICATION APT. CONDO. U)CONTRACTOR (f € NO. z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS P4414 NO.
(commencing with Section 7000)of Division 3 of the Business and CC LIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY ,/eY11 t CLASS VALIDATION
SQ. FT. NO. OF NO. OF CHECK BK. PG.
License Number Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK GP NEW ❑ $
LU 1�41�J1
®
❑ I am exempt under Sec. ADD ❑
ALTER
B.BP:C. for this reason REPAIR ❑ $
USE OF
Date: EXISTING BLDG. ` gt4JLE DEMOL ❑
Signature APPLICANT ) TEL. FINAL
OWNER-BUILDER DECLARATION PRINT ALT/�7J !j ' f ' NO.;Z96 7 L b —��DATE ;Q0.0 4,3 A
�+
I hereby affirm that I am exempt from the Contractor's License ADDRESS � °
Law for the following reason (Section 7031.5, Business and . FINAL # o o io 0 0
Professions Code): PR EN y� By rf
❑ BUILDING J Y.S K , J�/vF/ � t�. ;�:o o 4 7,8 8
I, as owner of the property, or my employees with ADDRESS ;,.-
wages as their sole compensation,will do the work and 4 9 8 8=
the structure is not intended or offered for sale(Section LOCALITY o 0 o 5
tin 7044, Business and Professions Code). MOVING ,�/ A TEL.
I N I, as owner of the property, am exclusively contracting CONTRACTOR ,f✓ 7T NO. 0 2 9 8 8
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK s
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 w rk for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L
Lender's Name \s `
�7 LD MA Ref. #:,
P.C. Fee$ Permit Fee& e MA
Lender's Address
3
$ I certify that I have read t is application and state that the Issuance Fee " D LDMA'P/C#.
above informati is correc. I agree to comply with all County Investigation Fee s w
0 ordinances an tate laws relating to b ildin construction,
o and hereby a ori representativves this County to enter Total Fee LDMA Perm. # `
upon the nti a roper inspection purposes. 1
a
8p SEE REVERSE FOR EXPLANATORY LANGUAGE s',?,
Signature of Applicant or Agent Date