HomeMy Public PortalAbout5801ALESSANDRO AVE_Building NTION bECLARATION -
ove a certificate of consent to self APPL
I( ®T I®I� FOR +B U I�L D I N G- PERMIT
y
,,ole of Workers' Compensation Insurance, vow\ i�
,copy�thereof
QQ(Sec. 3800,-Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL--INADDRESS
F-1 / t �� CrC/
Certified copy is filed with the county building inspec- BUILDING Sc��1 nC �,j "
tion department. ADDRESS
P
ry
Date. Applicant f ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' O.OF BLDGS. NEAREST
CC:YIPENSAi iON INSURANCE SIZE OF LOT NOW ON LOT CROSS"ST. Y (rsYJ -Ci�l�
(This section need not be completed if the permit.is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE I PARCEL
} TEL. US ONE= MAP -77
I certify that in the performance of the work for which this OWNER t�/1 �11 A�� r�: G�'�-I NO. NO.
permit is issued, I shall not employ any person in any manner ADDRESS ��'KAt - - SPECIAL L'
so as to become subject to the Workers'Compensation Laws. / CONDITIONS U
CITYZIP
Date Applicant G+r"~� %,'
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROESSED BY O
Exemption, you should become subject to the. Workers' ENGINEER NO. CONST. ZONE I '
Compensation provisions of the Labor Code, you must forth- ADDRESS A( 1 ) a
with comply with such provisions or this permit shall be y TEL STATISTICALCLASSIFICATION APT. LNDO. CL
deemed revoked. CONTRACTOR13v � izj�i pLyL N0 3 �12 i l LA_
LICENSED CONTRACTORS DECLARATION CLASS NO. ' DWELL. UNITS
�� LIC. . Z a
2
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 7 (f�L C- '�t/�NO. 1
(commencing with Section 7000)of Division 3 of the Business and -!! SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS BK VALIDATION
t-1 1 SQ. FT. Y NO. OF 1 NO. OF l CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE`
✓� V ATION
`J TG j5t}L's�LulL(7 -Z1 NEW 1:1 �{
Contractor ate DESCRIPTION OF WORK $
❑ 1 am exempt under Sec. ' �� LrL- ADD ❑ _ (/ Cf
ALTER
B.BP.C. for this reason 1- REPAIR ❑ $
Date: EXISTING BLDtti�L-L i ti-a kyl DEMOL
USE OF G ❑
Signature APPLICANT } STEL•.,' 3-1 2 FINAL..--) �R
PRINT 1 V. \ NO. 1� � �GG0 7 �SA
OWNER-BUILDER DECLARATION DATEi H
I hereby affirm that I am exempt from the Contractor's License F
Law for the following reason (Section 7031.5, Business and ADDRESS - �� ^M i`- F1NA
Professions Code): PRESENTBY
❑ BUILDING °
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ® ° o ° 6 IR6 3 6)
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL. Q C� 2_8 8❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS t
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM
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.). SIDE
P.L.
Lender's Name _
u y LDMA Ref. #
Lender's Address P.C. Fee$' Permit Fee 0 t 1 _ J
—
I certify that I have read this application and state that the Issuance Fee J °, LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total FeeLDMA Per
#
a �he e I authorize�piesent fives of this County to enter
u;Pon th a dve_m�ritied prop rty for inspection p�ur�poses.
/#� / �)•. I �` A7 SEE REVERSE FOR EXPLANATORY LANGUAGE
/Signature of Applicant_or''Agent '�-Date