HomeMy Public PortalAbout5802, 5808-10ALESSANDRO AVE_Building (3) WORKERS COMPENSATION DECLARATION f
affirm
atWorkers certif-icate of
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insure ora certificate orCompensa, �ueAPPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Se� 3800 Lab C ) 1 11
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COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company BUILDING — 9
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ,+ ADDRESS J 6P
e
❑ Certified copy is filed with the county building inspec BUILDING QC� An
Tion department ADDRESS AL,5 JJf'f'_�/ LOCALITY
i NEAREST A, ,
Date ApplicagA�- i_ JP rZ, CIT b`5 ZIP CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS / (l t �N OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT L(/ NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for oneUSE ZONE MAP pod 7 57
hundred dollars ($100)or less ) TRACT BLOCK LOT NO NO
TEL SPECIAL ° >-
I certify that in the performance of the work for which this OWNER `7�L NO CONDITIONS CL
permit is issued I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PR 0
SSED BY
so as to become subject to the Workers Compensation Laws ADDRESS �/ CONST ZONE
y Date Applicant CITY l ZIP STATISTICAL CLASSIFICATION APT CONDO 0
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT ^L NLO a LU
ENGINEER / �` CLASS NO DWELL UNITS
Exemption you should become subject to the Workers _fin- I H
Compensation provisions of The Labor Code you must forth ADDRESS G!/�/� SEWER
with comply with such provisions or this permit shall be
TELVALIDATION
deemed revoked CONTRACTOR NO - K L / +
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUA ION
(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 $ ,
SQFT /L O OF !� NO OF CHECK
License Number Lic Class SIZE y STORIES G7� FAMILIES ONE
S
Contractor Date DESCR TI�OF RK
1 r �— NEW
�� bCs �
4..�, � t3t09
t under Sec
❑ I am exempt ALTER FINAL 2 0,5 9 8 6 2 '
B&P C for this reason ❑ DATE
R IR
USE OF
Date EXISTING BLDG _ DEM E] B NAL ° 0 5 9 8 6 2 APPLICANT TEL Z
Signature �` PRINT NO 0 �_� ��8
OWNER BUILDER DECLARATION ,
I hereby affirm that I am exempt from the Contractor s License #;o o o o 23
Law for the following reason (Section 7031 5 Business and _ ADDRESS
Professions Code) PRESENT 2 •l0 99 44
BUILDING =
❑ I as owner of the property or my employees with ADDRESS - 0 0 0 99 4 4
wages as their sole compensation will do the wok and
the structure is not intended or offered for sale(S tiontALITY - 0 92 1 -8 4
7044 Business and Professions Code) , VING
❑ I as owner of The property am exclusively contracts g CONTRACTOR NO 4 339 A
with licensed contractors to construct the project (Se
0 0 0 0 0 1
tion 7044 Business and Professions Code) RESS _ 2 ro t$3 1 75
QUIRED TOT L SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY T BACK YARD HWY PROP LINE WIDTH o 0 8 3 1 7 5 cZ�
I hereby affirm that there is a construction lending agency forONT
the performance of the work for which this permit is issuedL �, 0 9 2 1 —84
(Sec 3097 Civ C ) DE
FO L- c
Q Lender s Name ``
Fe b� Permit Fee 1
Lender s Address , �t v
I certifythat I have read this application and state that the
pp Issuance Fee J -
a above information is correct I agree to comply with all Countystigation Fee
ordinances and State laws relating to building construction Total Fee
Ly and hereby authorize representatives of this County to enter
upon the above mentioned property for inspection purposes
�i Y
Qom$ 9�A SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date ®i