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HomeMy Public PortalAbout5542ALESSANDRO AVE_Building (4) ;WORKERS'COMPENSATION'DECLARATION J •I hereby affirm that I±have a certificate of consent, to Self A P P'L LCAT I ON, FOR BUILD I N G•' 'E RM I T nsure, or a certificate of Workers' Compensation Insrance, or ckertified copy thereof (Sec. 3800; Lab. C) 11 t . . • I. ANGELES BUILDING AND SAFETY • . .,4 ,. . ... - - - COUNTY OF LOS ANG Policy No., ' � . Company - ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ' ADDRESS Certified copy is.filed with the county building i'nspec- BUILDING ' tion dep'a'rtment. + ADDRESS Date' Applicant' CITY zip LOCALITY LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' ''`4 NO.OF BLDGS: NEAREST .. . _ '''COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (Th'is'section need not be completed if the permit is for one ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK GE: PARCEL certify that in The performance of the work'for which this ' S 0. TEL. U E NE. n OWNE i t 6 1 t,I NOL Z� oL permit is issued,1 shall not employ any pe'rson'in any manner. r l SPECIAL "� 9L so.as to be/!c�Iom/e subject to the Work s'Co pe satin Laws. ADDRESS 1 f Y�1'�3-C' CONDITIONS O Y �b g� e.,, ,.- , CITY"' �'1 ZIP. ARCHITECT O TEL. O Date "Applicant VVP NOTICE'TO�APPLICANTi If, after-ma ng this Certificate of DISTRICT GROUP ,TYPE FIRE PR CE ED BY - ENGINEER NO. CONST.I ZONE. ) Exemption, 'you should become sJbi to the Workers' "' /� Compensation provisions..of the Cabo ode;>you must forth- Fr' aJ�VV �;! ADDRESS y with comply with such,provisions'orothis perrnit shall be TEL STATISTICAL CLASSIFICATION APT. C O. deemed,revoked. ;... CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. - - DWELL. UNITS hereby affirm that l am licensed under provisions of Chapter 9 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 BK PG VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic.'Class SIZE STORIES � FAMILIES � ONE- a .. VALII TION DESCRIPTION OWORK NEW F' Contractor =Dater ADD ❑ $ D ❑ I am exempt under Sec. ALTER El r B.&P C.1for this reason oL}►r REPAIRUSE OF ❑ S z"�_ .Date: EXISTING BLDG. DEMOL ❑ !C 1 APPLICANT TEL.. Signature FINAL/- # 0 0 0 o O'l OWNER-BUILDER DECLARATION- PRINT) NO I hereby affirm that I am exempt_from.the.Contractor's License Law for the following:-reason (Section 7031.5, Business and ADDRESS FIN ( ® 0 2 0 Professions'Code): PRESENT BY' / &5` BUILDING 9. 1, as owner of the property, or m employees with ADDRESS __, 1. 0 0 '©; P P v, y . 2$50.x.. wages as�their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 6 0 3-•8 5 7044; Business and Professions Code). MOVING TEL. ' I, as owner of the property, am exclusively contracting CONTRACTOR NO. with'licensed contractors'to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED CONSTRUCTION LENDING AGENCY SETT BACK YARD -HWY TOTAPROP.LINESETBCKFROM WIDTH I hereby affirm that there is a construction lending agency for FRONT --the performance of the work for which this-permit Js issued P.L. - (Sec. 3097, Civ. C.). SIDE Lender's Name m /f LDMA Ref. # - ._ P.C.-Fee$" -- - Permit Fee Lender's Address I.certify that,I have read_this application and state that the Issuance Fee LDMA P/C# , above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws.relating to building construction, Total Fee LDMA Perm::-# t v and hereby guthorize repipbsentativ of this County to enter upon th ove- enTioned prop. y for inspection la ur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE �Signat f-Applicant or Agent Date i