HomeMy Public PortalAbout5754ALESSANDRO AVE_Building (3) r WORKERS COMPENSATION DECLARATION
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insureboraafcertif certificate of firm that I Worke srtCompensat on eInsuran elf APPLICATION F®R BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C )
,, s COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
rtified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Ceertified copy s filed with the county building inspec BUILDING C
tion department a ADDRESS V
Date '� pplicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS ' c ,INO OF BLDG NEAREST
COMPENSATION INSURANCE
SIZE OF LOT NOW ON LOT CROSS ST
(This section need not be completed if the permit is for one TRACT ( ASSESSOR
hundred dollars ($100)or less ) BLOCK LOT NO p MAP BOOK PAGE PARCEL
u
OWNERC O Z - USEPNE MAP e
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 SPECIAL
so as to become subject to the Workers Compensation Laws ADDRESS CONDITIONS 0
F iU
CITY ZIP
Date Applicant ARCHITECT OR TEL
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO DISTRICT T
P TYPE FIRE PROCESSED BY O
Exemption you should become subject to,the Workers CONST L/
/ ZONE U
Compensation provisions of the Labor Code you must forth ADDRESS 5r41 �/ W
4v
with comply with such provisions or this permit shall be TEL 0-
deemed,revoked CONTRACTOR NO �� STATISTICAL CLASSIFI ATION APTLN� Z
LICENSED CONTRACTORS DECLARATION LIC ^f CLASS NO (7/�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 and LIC— SEWER MAP
Professions Code, and my license is in full force and effect CITY 1 CLASS — BK VALIDATION
f
f 5 SO FT NO OF NO OF CHECK
PG
License Number i2�� 1 7 Lic Class yy�� SIZE STORIES FAMILIES ONE /1
.~ E_ � � Z 1 �U DESCRIPTION OF WORK NEW ❑ VALUATION
Contractor Date
❑ r / / ❑
l 2 ADD ,
I am exempt under Sec (�L
ALTER
B 8P C for this reasonUSE OF _ ' REPAIR ❑ $
Date µ EXISTING BLDG DEMOL ❑
Signature - r APPLICANT TEL FINAL /T-
OWNER BUILDER DECLARATION PRINT NO DATE ' v
I hereby affirm that I am exempt from the Contractors License `
Law for the following reason (Section 7031 SV Business and ADDRESS FIN
28813A
Professions Code) PRESENT BY
❑ BUILDING # 0 0 o io io i1
I as owner of the property or my employees with ADDRESS
wage as their sole compensation will do the work and 0 - 4988
the structure is not intended or offered for sale(Section LOCALITY =
7044 Business and Professons Code) - MOVING TEL • • o 4 9 8 8 c0
❑ I as owner of the property am exclusively contracting CONTRACTOR NO 0 1 2 1 -88
with licensed contractors to construct the project (Sec
tion 7044 Business and Professions Code) ADDRESS
FROM ty.1�11
CONSTRUCTION LENDING AGENCY SETT BACKK YARD HWY TOTAL
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
Lender s Name
LDMA Ref #
m r
PC Fee E Perm t Fee
Lender s Address
I certify that I have read th s application and state that the Issuance Fee LDMA P/C# ` {
oabove information is correct I agree to comply with'all County Investigation Fee
qj
o ordinances and State laws relating to building construction Total Fee LDMA Perm #
and hereby authorize r resentatrves of this County to enter
q upon t ab ve ent ed property for inspection purposes
a , � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date