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HomeMy Public PortalAbout5754ALESSANDRO AVE_Building (4) WORKERS COMPENSATION DECLARATION hereby affirm that I have a certificate of consent self APPLICATION FOR BUILDING PERMIT insure or a certificate of Workers Compempenstion Insurance e or , a certified copy thereof (Sec 3800 Lab C ) PolicyNo230770 company State Comp COUNTY OF LOS ANGELES , BUILDING AND SAFETY NG ❑ copy v FOR APPLICANT TO FILL IN A��RE S Certified co is hereby furnished © Certified copy is filed with the o my building inspec BUILDING tion department ADDRESS 5754 Alessandro LOCALITY _ NEAREST Date 11/1/8 0 Applicant CITY Temple Cit� ZIP - - CROSS ST CERTIFICATE OF EXEMPTION FROM WOR R NO OF BLDGS 1 ASSESSOR COMPENSATION INSURANCE SIZE OF LOT _ NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one { 5 USE ZONE MAP hundred dollars ($100)or less ) TRACT ✓ BLOCK LOT NO ��' NO 6 TEL SPECIAL d I certify that in the performance of the work for which this OWNERVan Gorder -NO 286-4615 CONDITIONS O permit is issued I shall not employ any person in any manner DISTRIC.j GROUP TYPE FIRE PROC SS F�Q BY V so as to become subject to the Workers Compensation Laws ADDRESS 5754 Alessandro �nY � CONST / ZONE O Date Applicant CIT C ZIP STATISTICAL CLASSIFICATION v APT JC0 U UJ NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL Exemption you should become subject to the Workers ENGINEER NO CLASS NO _DWELL UNITS N Compensation provisions of the Labor Code you must forth ADDRESS - - SEWER MAP with comply with such provisions or this permit shall be // / deemed revoked , CONTRACTO R T L _ BK ` PG J3 VALIDATION LICENSED CONTRACTORS DECLARATION Q 68 Truck Way L'�248852 I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES y NO VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC / - Professions Code and my license is in full force and effect CITY Montebello CLASS C-39 b 1322,00 SQ FT NO OF NO OF CHECK License Number 248852 Lic Class C-39 SIZE STORIES FAMILIES ONE t ContractoM. ontebello Rf agate 11/7/80 j DESCRIPTION OF WORK Reroof existiri NEW ❑❑ $ ❑ ADD I am exempt from the licensing requirements as I am a I �a T shingles Q licensed architect or a registered professional engineer I ALTER ❑ FINAL acting in my professional capacity (Section 7051 Business and Professions Code) DATE USE OF REPAIR EXISTING BLDG dwelling - DEMOL ❑ FINAL ��.`... Lic or Reg No Date y APPLICANT TEL OWNER BUILDER DECLARATION - _ ((PRINT) - - - NO - J I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and ADDRESS T� Professions Code) PRESENTT ElBUILDING _ 930688 I as owner of the property or my employees with J ADDRESS # 0 0 o e o wages as their sole compensation will do the work and 2 0 0 3 ILO 0 the structure is not intended or offered for sale(Section LOCALITY 0 0 0 3 4 0 0 C 7044 Business and Professions Code) MOVING TEL ❑ I as owner of the property am exclusively contracting CONTRACTOR NO 1 1 1 4 -8 0 ' with licensed contractors to construct the project (Sec ADDRESS tion 7044 Business and Professions Code) REQUIRED TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD HWY 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 ) r SIDE LInvestig9tion Lender s Name Permit Fee 27e00 Lender s Address ` 7e00w I certify that I have read this application and state that the Issuance Fee above information is correct I agree to comply with all County ee ordinances and State laws relating to building construction Total Fee 34-00 a and he y authorize representatives of this County to enter 4 M1 a upon e above mentioned property for inspection purposes 1 Pres. 11/7/80 SEE REVERSE FOR EXPLANATORY LANGUAGE igna e oAy,cant or Agent Dote ®: