HomeMy Public PortalAbout5745ALESSANDRO AVE_Building (2) WORKERS"COMPENSATION DECLARATION "EM
hereb,�la cer That I hate a certificate of consent to selfAPPLICATION FOAR �UI�„ S N C I T
insure, or a certificate of W'arkers' Compensation Insurance,
or a certified copy thereof (Sec. 38`c00, Lab. C. COUNTY OF LOS ANGELES BUILDINi-G AND"rSAFETY-
Policy No. ilk S�1 Company
ElBUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
Date Applicant CITY ( ZIP 217
f50
LOCALITY
CERTIFICATE OF EXEMPT FROM WORKERS NO. OF BLDGS. NEAREST
COMPENSATION SIZE OF LOT �j J d NOW ON LOT 2 CROSS ST.
INSURANCE (y L'
(This ASSESSOR
section need not be completed if the permit D TEL.is for one TRACT' �7 BLOCK O LOT NO. v MAP BOOK Q 575DO g PAGE T PARCEL
OWNER CIL
hundred dollars ($100) or less.) I � AflZG!/ NO. �USE ZONE MAP a
NO.
I certify that in the performance of the work for which this ��`O /4/v-.
^ SPECIAL }
permit is issued, I shall not employ any person in any manner ADDRESS �! CONDITIONS a.
so as to become subject to the Workers'Compensation Laws. Q
CITY � le L" zip �7 �d. U
Date Applicant ARCHITECT OR TEL. �
NOTICE TO APPLICANT:. If, after makingthis Certificate of ENGINEER 0A, NO. DISTRICT GROUP TYPE FIRE PROCESSED BY
CONST. ZONE 0
Exemption, you should become subject to the Workers' /`' j U
Compensation provisions of,the Labor Code, you must forth- ADDRESS ,�' - V �y C-L
with comply with such provisions or this permit shall be TEL.Z STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. � CONTRACTOR Cp' li'M� � v NO. � 6- /�/
Z
LICENSED CONTRACTORS DECLARATION //� LIC. CLASS NO.�DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS . O O -3'G Z_ NO. 4/03`J
C / y�
(commencing with Section of Division 3 of the Business SEWER MAP
CITY &c� ,/fes f LIC.CLASS G2—V / `
and Professions Code;and myy license is in.full force and effect. BK.Ii- PG. VALIDATION
/� 7 SQ. FT. NO. OF l NO. OF , CHECK
License Number / 017 Lic. Class C?--/3 SIZE - STORIES ( FAMILIES ONE
y+ / ^� J4 4dtJ �S VA LU TION
ContractorA�NGIIpv �-MEi✓l Date ! .c�J—9� DESCRIPT O WORK NEW ❑
l I ADD S
❑1 am exempt under Sec. A G 15 ilk /NAGS/Jd4 r-e ,[ ALTER ❑
B.&P.C. for this reason r .K���e f`��G�G/1 'V T� REPAIR ❑ $
Date: USE OF
EXISTING BLDG. S b / n ! h / DEMOI ❑
Signature APPLICANT TEL.?.(.3
FINAL
TER-BUILDER DECLAR ION (PRINT) 6tpv t O NO. $Y6�bD �j
DATE
/ 7
I hereby affirm that I am exempt from the Contractor's License
rADDRESS ` O 6 l�q t7i FINAL
Law for the following
reason (Section 7031.5,'ELsiness and
Professions Code): PRESENT By
❑ I, as owner of the property, or my employees with ADL ESS rmo /reA-m 'Z1�/ �rtav
wages as their sole compensation,will do the work and LOCALITY �4 v 6{r w� lout`♦{ aG ' (•
the structure is not intended or offered for sale(Section -
7044, Business and Professions Code.) MOVING TEL _T ;
❑ I, as owner of the property, am exclusively contracting CONTRACTOR �, /) l.v(i/LitOi�/ iEl',_r
with licensed contractors to construct the project.(Sec- ADDRESS T?_l '-EL -
tion 7044, Business and Professions Code.) _
REQUIRED TOTAL SETBACK FROM EXIST.. r:�' -)
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH L:I l
I hereby affirm that there is a construction lending agency for FRONT _{"If[h; atw`(
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C:). SIDE
P.L.
Lender's Name, r i 0 i j€ •'
$ 45
LDMA Ref. # W t :y_•
Lender's Address P.C. Fee$ Permit Fee
0 1 certify that I have read this application and state that the Issuance Fee LD AA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee
R ordinances and State laws relating to building construction, Total Fee �� LDMA Perm. #
a and hereby authorize representatives of this County to enter
u he above-mentio ed property pr inspection urposes.
./
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant o gent Date -