HomeMy Public PortalAbout5740ALESSANDRO AVE_Building '•-WORKERS' COMPENSATION DECLARATION
hereby
that
certificate
consent
acertifate have
WokesCompensaton rsurn APPLICATION FOR BUILDING PERMIT
-or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS C. Q
❑ Certified copy is filed with the county building inspec- BUILDING _— '1 a
tion department. ADDRESS ( U
i O
Date Applicant CITY Q C ZIP LOCALITY
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT C, NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) 1 TEL. 7�� p�r�
OWNER �eYT l /� / ✓ USE MAP
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL a
CONDITIONS
so as to become subject to the Workers' Compensation Laws. /�'' , O
CITY 1 C ZIP912150
Date Applicant ARCHITECT OR _ TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If,.after making this Certificate of ENGINEER Q NO. n CON E
Exemption, you should become subject to the Workers' D� �_aJ ` U
Compensation provisions of the Labor Code, you must forth- ADDRESS Y a
with comply with such provisions or this permit shall be ,^ TEL. STATISTICAL CLASSIFICATION APT. I CONDO. N
deemed revoked. CONTRACTOR NO. Z
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
LIC. SEWER MAP
and 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
VALUATION�,
Contractor Date
DESCRIPTION OF WORK ❑ $ v O 0
El am exempt under Sec. ADD ►
ALTER ❑
B.&P.C. for this reason REPAIR ❑ $
Date:' U§E OF ; DEMOL ❑
EXISTING BLDG.
Si nature APPLICANT '^ _� �O TEL.
P g (PRINT) V V O O NO. - FINAL r
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL a
rof ssions Code): PRESENT By T-
BUILDING
I, as owner of the property, or my employees with ADDRESS
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 TEL. ® Civi_
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. a 's�;t•
e
with licensed contractors to construct the project (Sec-
ADDRESS 1•.t_ 3 • = 00
tion 7044, Business and Professions Code.)
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. 5-A-C�' f_ ',i a.?
CONSTRUCTION LENDING AGENCY SET BACK 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,
m
LDMA Ref. # -_
P.C. Fee$ Permit Fee -•-r•1,: 4, ;•;F-•-:
Lender's Addresspol. ,
0 1 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
R ordinances and State laws relating to building construction, Total Fee 29 49 LDMA Perm. #
a and hereb authorize repre ntatives of This County to enter
upon o yeion pr rty r inspection purposes.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Appl ant "Agent kDate