HomeMy Public PortalAbout5801ALESSANDRO AVE_Building (4) WORKERS' COMPENSATION DECLARAI ON '
hereby affirm that I havecertificate of consent`to self - APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance, � '
or a certified copy thereof (Sec. 3800, Lab. C.) W - COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with the county building inspec- BUILDING QQ J�,GG //�1 n
tion department. ADDRESS 51601 •ss'�' 5 r"Y0AO /� G LOCALITY �/0�-&t7NEARE
Date Applicant �•` CITY ^01,1 L . uT ZIP L�7 O CROSS ST T. L4-00 DRKY"'t
CERTIFICATE OF EXEMPTION FROM WORKERS' ['� 0 NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT v _ )K I v NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if.the permit is for one / --- h.�-Lr1 USE ZONE MAP
hundred dollars ($100)or less.) TRACT (C� BLOCK LOT NO. v7� Z-- NO.
TEL. n�ir�(t�v SPECIAL 9L
OWNER /w1 Q Y /,V NO:.2 � / CONDITIONS �
I certify that in the performance of the work for which this ��^► ���Q DISTRICT GROUP TYPE FIRE PROCESSED BY O
permit is issued, I shall not employ any person in any manner ADDRESS J(j�� <«7z/N�� CONST. ZONE U
so as to become subject to the Work rs'Co ensati Laws. /yam/ (� ;z,- :—
V
/
CITY �L+� � 3 10/2.rr
�'i
Date Applicant ZIP �t�7 p STATISTICAL CLASSIFICATION APT. ICONDO.
NOTICE.TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL.
Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. �/ DWELL. UNITS
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWE MAP
with comply with such provisions or this permit shall be
deemed revoked. TEL.. BK P
CONTRACTOR NO. G VALIDATION
LICENSED CONTRACTORS DECLARATION W LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUA05$
(commencing with Section 7000)of Division 3 of the Business and LIC. /
Professions Code, and my license is in full force and effect. CITY CLASS $
SQ. FT. ;�L[ NO. OF NO. OF CHECK
License Number Lit.Class SIZE JJ STORIES FAMILIES ONE
—
Contractor Controctor Date $
DESCRIPTION OF WORK �I�'1. � NEW ❑
ADD
I am exempt under Sec.
t ALTER ❑ FINAL
B.BP.C. for this reason REPAIR ❑ DATE
USE OF
Date: EXISTING BLDG. DEMOL FIN
❑
B ,
Signature APPLICANT TEL.
OWNER-BUILDER DECLARATION PRINT NO.
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and ADDRESS
rofessions Code): PRESENT J g g 2 A
/ BUILDING v
I, as owner of the property, or.my employees with ADDRESS 0 0 0 0 0 1
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY % 1 3 4,2 5
\ 7044, Business-and Professions Code). MOVING TEL. c c 1 3 G.2 rJ x
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
❑� with licensed contractors to construct the project (Sec- �, 1 4-83
tion 7044, Business and Professions Code). ADDRESS
REQUIREDTOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HViY 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
o P.L.,
o Lender's Name _
Lender's Address P.C. Fee$ Permit Fee
I certify that l have read this application and state that theIssuance Fee C)+ L
a above information.is correct:I agree to comply with.all County Investigation Fee
ordinances and State.lows relating to building construction, y..Z(,�•
u and hereby authorize representatives of this County to enter Total.Fee. /
9 upo the ab J ' men ed property for inspec��tiaao purposes.
L✓' 'L IiA/6 SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nat re of Applicant or Agent ®s
9 PP 9