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HomeMy Public PortalAbout5802, 5808-10ALESSANDRO AVE_Building (2) WORKERS COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure or a certificate of Workers Compenstion Insurance or a certified copy thereof (Sec 3800 Lab C ) - COUNTY OF LOS ANGELES F BUILDING AND SAFETY Policy No Company BUILDING /�� Certified copy is hereby furnished ' FOR APPLICANT TO FILL IN ADDRESS f 0 Certified copy is filed with the county building mspec BUILDING �td.� f� tion department ADDRESSV02 �JJ�>u1I /<V - LOCALITY �i CAF µO JW" NEAREST t Dare � 1 Applicant CITY a.� ZIP / CROSS ST a ERT KATE OF EXEMPTION FROM WORKERS t NO OF BLDGS ASSESSOR COMPENSATION,INSURANCE SIZE OF LOT _ NOW ON LOT i. r MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one _ USE ZONE MAP hundred dollars ($100)or less ) TRACT BLOCK LOT NO ' NO TEL ^ SPECIAL O. r 1 certify that in The performance of the work for which this L OWNER F ((/ / NO CONDITIONS"i DISTRICT GROUP TYPE FIRE PROCESSED BY V r permit is issued I shall not employ any person in any manner ADDRESS L� RD CONST ZO E so as to become subject to the Workers Compensation,Laws ) O Date Applicant ' t CITY C ZIP STATISTICAL CAL CLASS FICATION AP CONDO V ENGINEER NO NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR t TEL Exemption you should become subject to the Workers - CLASS NO _DWELL UNITS d Compensation provisions of the Labor Code you must forth ADDRESS 16 (. . M S T SEWER MAP with comply with such provisions or this\permit shall be TEL ' deemed revoked CONTRACTOR N09141rb—&N BK PG VALIDATION ,LICENSED CONTRACTORS DECLARATION LIC _ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION C (commencing with Section 7000)of Division 3 of the Business and f LIC fIII Professions Code and my license is in full force and effect Y CITY U/• C•O(J/�14 CLASS �F $ 6�U /www ' SQ FT NO O NO OF CHECK License Number 220W- ' Lic Class SIZE D STORIES 1Z FAMILIES ONE r r /�GAMD #VX0CU 2a t $ - DESCRIPTION OF WORK NEW Contractor Date ADD` ❑ � I am exempt from the licensing requirem nts as I am o r /rwr/ ❑ licensed architect or a registered professional engineer ALTER FINAL 7 acting in my professional capacity (Section 7051 + REPAIR ❑ DATE Business and Professions Code) _ USE OF EXISTING BLDG L �tlM� DEMOL ❑ By AL Lic or Reg No Date APPLICANT r TEL - r OWNER BUILDER DECLARATION- - -(PRINT) NO 0� I Hereby affirm that I am exempt from the Contractor s License r p. [aY�N Law for the following reason (Section 7031 5 Business and ADDRESS (y Professions Code) PRESENT ❑ ti BUILDING 9 I as owner of the property or my employees with ADDRESS 43 wages as their sole compensation will do the work and _ E the structure is not intended or offered for sale(Section LOCALITY 1 2 6 4 U. 1 A 7044 Business and Professions Code) MOVING TEL ❑ I as owner of the property am exclusi hely contracting CONTRACTOR NO 4F, `�� - # o e o'`e • 1 with licensed contractors to construct the project (Sec + tion 7044 Business and Professions Code) FADDR ,,� �ati ai> 1'6 9 0 0 CONSTRUCTION LENDING AGENCY D TOTAL SETBACK FROM EXIST' O T , K YARD HWY PROP LINE WIDTH o'� 1 6 9 0 0 c=. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued I `0'924-82 (Sec 3097 Cry C ) -Lenders NameLender s Address d p Permit FeeA. �./ certify that I have read this application and state that the Issuance Fee r/ bove information is correct I agree to comply with all County = Investigation Fee = rdmTotal Fee ances and State laws relating to building construction Y nd hereby authorize representatives of this County to enter - pan the a v endo ed roperty for inspection purposes lr �L -- SEE REVERSE FOR EXPLANATORY LANGUAGE M Signature of Ap is t or Agent Dote ©s