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HomeMy Public PortalAbout5802, 5808-10ALESSANDRO AVE_Building (4) WORKERS COMPENSATION DECLARATI(.NY I r Ihereynsureboraafcertifi afirm tlqattedi WorkesriCompensaronInsua4)cef T !--",-APPLICATI N FOR-BUILDING PERMIT or a certified copy thereof (Sec 3800 Lab C ) r COUNTY -1,0S ANGELES BUILDIN AN SAFETY Policy No Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESSILDING , Certified copy is filed with the county building inspec BUILDING �Q•/ tion department ADDRESS LOCALITY nn f NEAREST Date Applicant CITY �,r� t 1 ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERSg�s NO OF BLDGS s ASSESSOR COMPENSATION INSURANCE SIZE OF LOT /V 0 X I Z--� NOW ON LOT I ` MAP BOOK PAGE PARCEL This section need not be completed if theUSE ZONE ermit is for one J (, MAP hundred dollars ($100)or less ) p TRACT 651 1 BLOCK LOT NO NO DD rr//�� /� TEIy/ SPECIAL I certifythat in the performance of the work for which this f OWNER F-6 ��IG JT�� NO n ^7�.5 CONDITIONS 0. p _ t� DISTRICT GROUP TYPE FIRE PROCESSED BY O permit is issued I shall not employ any person in any manner ADDRESS 3 F ASN R►" CONST ZO U 4Date so as to become subject to the Workers Compens do awsApplicant c CITY ZIP ` STATISTICAL CLASSIFICATION (/ APT CONDO 0 NOTICE TO APPLICANT If afte making this ertificote of ARCHITECT OR , r4 1�I q TEL ry Exemption you should become subject to the Workers ENGINEER JJ rl NO CLASS NO _DWELL UNITS � Compensation provisions of the Labor Code you must forth ADDRESS " SEWER MAP N with comply with such provisions or this permit shall be Z TEL deemed revoked CONTRACTOR NO BK VALIDATION LICENSED CONTRACTORS DECLARATION LIC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION (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 $ F SO FT/ NO OF NO OF CHECK ► �.� ' License Number Lic Class SIZE / �© STORIES FAMILIES ONE I DESCRIPTION OF WORK �A NEW § Contractor Date t0 ADD 0 I am exempt under Sec V ALTE _FINAL ' 4r B 8P C for this reason REPAIR DATE '� S USE OF FINAL Date EXISTING BLDG DEMOL B Y �J Signature APPLICANT TEL OWNER BUILDER DECLARATION _ PRINT NO , 2- I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and ADDRESS Professions Code) PRESEMT ❑ BUILDING I as owner of the property or my employees with r ADDRESS 9 wages as their sole compensation will do the work and r �/ the structure is not intended or offered for sale(Section LOCALITY �I' Q c1 7044 Business and Professions Code) f MOVING TEL _ I as owner of the property am exclusively contracting CONTRACTOR NO with licensed contractors to construct the project (Sec ADDRESS tion 7044 Business and Professions Code) REQUIRED TOTAL SETBACK FROM EXIST w 4 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 eC (Sec 3097 Civ C ) SIDE m PL Q Lender s Name Y \ i t1 C_ 0" r� • �� �> $ PC Fee$ F Permit Fee " Lender s Address ;7/ p� ' 0 4' O I certify that I have read this application and state that theIssuance Fee sh r above information is correct I agree to comply with all County Investigation Fee + r ordinances and State jaws relating to building construction I Total Fee �1 and hereby authorize reprVproes of this County to enter upon t ve mentionsy for sp501on purposes - v c SEE REVERSE FOR EXPLANATORY LANGUAGE " Signature of App cant or Agent Date Os r