HomeMy Public PortalAbout5801ALESSANDRO AVE_Building (3) WORKERS' COMPENSATION DECLARATION 'J
insure,hereby
aa certificate of Workers' Compensat on ffirm that I have a certificate of cotnt o self APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS I AI-z4,d_th.�,L
❑ Certified copy is filed with the county building inspec- BUIADDLIDING
RESS
tion department.
Date • Applicant CITY' ZIP LOCALITY
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT tV X l C O NOW ON LOT ( CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK I LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) � DQ TEL• / USE ZONE MAP
OWNER ELS ti Ci�w� NO.1P Zt
3 0 NO.
I certify that in the performance of the work for which thisA _
SPECIAL >_
permit is issued, I shall not employ any person in.any manner ADDRESS .tZ4.d �""` CONDITIONS a-
so as to become subject to the Workers' Compensation Laws. �� O
CITY ✓k ZIP
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPEFIRE PRO S BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST ZONE 0
Exemption, you should become subject to the Workers' Q
Compensation provisions of the Labor Code, you must forth- ADDRESS , (j JJJ _ N
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. _
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business
LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE 3 Z STORIES FAMILIES ONE
� r VALUATION
Contractor Date DESCRIPTION OF WORK j X NEW ❑
ADD 10 '$ pop.ElI am exempt under Sec. J`
ALTER ❑
B.BP.C. for this reasonREPAIR 1:1
$
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT / TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT) Q a)-C f CkA,.� NO. -:3 DATE -- -�
I hereby affirm that I am exempt from the Contractor's License ADDRESS t� AIo.� l FINAL -
Law for the following reason (Section 7031.5, Business and .,.._
Professions Code): PRESENT By :.
BUILDING • G rI, as owner of the 'property, or my employees with
ADDRESS
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. , _
0 I, as owner of theproperty, am exclusive) contracting CONTRACTOR NO. -
Y 9 :--tt,-
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) ?;t• s t-,
3:t::
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. - m
CONSTRUCTION LENDING AGENCY SET ACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT t_. !_C_.� �` _w
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
Lender's Address -
o I certify that I have read this application and state that the Issuance Fee LDMA P/C# ►
8 above information is correct. I agree to comply with all County Investigation Fee
8 ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
a and hereby authorize representatives of.this County to enter
upon the above-.mention d property for inspection pur oses.
(�(.- 4.1 � - Io� 7/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Applicant or Agent Date