HomeMy Public PortalAbout5750ALESSANDRO AVE_Building (3) �+ WGRKERa=COMPENSATION DECLARATION
insure byhbre
certificate cate of Workers' Compensation onve a certificate of Insurance,nt to self APPLICATION FOR �d�1 I L-D I N C "PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Paley N.4 914291 comA-4tg Corp. Ins. Fund
❑ Certified copy is hereby furnishedBUILDING, . FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the my�;i,.nZgnec- BUILDINGtion department. ADDRESS 5750 Alessandro
Date -29-91. Applic iCITY ZIP LOCALITY
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FR&M WORKE SIZE OF LOP NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR �j'� y
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK J �� PAGE ODs PARCEL
hundred dollars ($100) or less.) TEL. �p�–W p�
OWNER Lonna Caorgino NO GW �7
// USE ZONE OP
I certify that in the performance,of the work for which this SPECIAL �
permit is issued, I shall not employ any person in any manner ADDRESS 5750 Al lesandro / CONDITIONS
so as to become subject to the Workers' Compensation Laws. Q
CITY LeWle City zip 91780
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If_after making, this Certificate of ENGINEERNO DISTRICT �GROUP TYPE FIRE PROCESSED BY
CONST. ZONE 0
Exemption, youshould become subject to
the Workers' �D _ 1 L-1, U
Compensation provisions of the Labor Code, you must forth- ADDRESS !� w
with comply with such provisions or this permit shall be TEL. �O STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. 287-1131 —
LICENSED CONTRACTORS DECLARATION LIC CLASS NO. C> UNITS
ADDRESS 8812 Las Tunas Drive NO 205344
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business C /+.� LIC.
and Professions Code,and m license is in full force and effect. CITY San Gabriel CLASS B
�n y BK. G PG. �, VALIDATION
License Number 205 !4
SQ. FT. NO. OF FA OF CHECK
L c. Class C + B-1 SIZE STORIES FAMILIES ONE
4 � DESCRIPTION OF WORK NEW El
VALUATION
Contractor ate 8-29-91
El am exempt under Sec.
Pumve and install new cabinets ADD R $ 9 372.00 ►
ALTER
B.BP.C. for.this reason tile countersand floors REPAIR ❑ $
te: USE OF
EXISTING BLDG. DEMOI ❑
APPLICANT FINAL
Signat r (PRINT) NO.
NER-B ILDER DECLAR ION 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 _
Professions Code): PRESENT By
❑ I, as owner of the property, or my employees with BUILDINGADDRESS
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. – -
1, as owner of the property, am exclusively contracting CONTRACTOR NO. s i
with licensed contractors to construct the-project (Sec-
ti
Sec- –
ADDRESS ?i HL 1 63 = v'^3
tion 7044, Business and Professions Code.) _
REQUIRED TOTAL SETBACK FROM EXIST. CHECK
CONSTRUCTION LENDING AGENCY SET BACK YARD 'HWY PROP. LINE WIDTH `" t " "
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.
LDMA Ref. #
P.C. Fee$ Permit Fee r; ,,,. �^ °=
Lender's Address
0 1 certify that I have read this application and state that the Issuance Fee LDMA P/C# Pilo
S above information is correct. I agree to comply with all County Investigation Fee.
0 ordinances and State laws relating t building construction, Total Fee /v/a �' LDMA Perm. #
a and her horize repr "entati sof this County to enter
upon th ove-mentio pro `y for inspection urpos/
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re 4Applican or Agent Dafe