HomeMy Public PortalAbout5816ALESSANDRO AVE_Building (2) WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
ElJ 'e p Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS / /V,
❑ Certified copy is filed with the county building inspec- BUILDINGn� �^
tion department. ADDRESS J J i '�V JT t'S��t' rQ ei-nOle-
Date-
1� ��►—
Date Applicant CITY' Ole— �� � ZIP / /7 f 0 LOCALITY
t-� NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION'FROM WORKERS' SIZE OF LOT v x I LL
NOW ON LOT CROSS ST. U/li
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACTL _ LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100)or less:) f-_ TEL. / USE ZONE MAP
OWNER' t/lfi t V�}F-� NO.� IIZh NO.
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS 1 CONDITIONS a
so as to become subject to the Workers'Compensation Laws. O
CITY ZIP U
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER "{�j� NO. DISTRICT GROUP CONS TYPE FIREE OCESSED BY Q
Exemption, you should become subject to the Workers' 30
U
Compensation provisions of the Labor Code; you must forth- ADDRESS (� �� C a
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. N
Z
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. c=�21 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 STORIES FAMILIES ONE
p, VALUATION
Contractor Date DESCRIPTION OF WORK Z gD NEW ❑ $ C) 10
El ADD r ►
I am exempt under Sec. Gc/ ❑
011111111111111111
ALTER
B.BP.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BL DEMOL ❑
Signature APPLICANT T&YFINAL
OWNER-BUILDER DECLARATION (PRINT) NO. DATE
I hereby affirm that I am exempt from the Contractor's License t 1
Law for the following reason (Section 7031.5,Business and ADDRESS FINAL
Professions Code): PRESENT
By /� ACCTa.r
ElBUILDING
I, as owner of the property, ormy employees with ADDRESS fr 3303 108.91 l
wages as their sole compensation,will do the work and tJJ 1 ITEMS the structure is not intended or offered for sale(Section [ADDRE
ALITY 1 ITE!tS
7044, Business and Professions Code.) VING TEL.
❑ I, as owner of the property, am exclusively contracting NTRACTOR NO. TOTAL 1083 m 90
with licensed contractors.to construct the project (Sec- -
SS CHECK 108.90
ADDRESS-
tion 7044, Business and Professions Code.)
EQUIRED TOTAL SETBACK FROM EXIST. u {�
CONSTRUCTION LENDING AGENCY ET BACK YARD HWY PROP. LINE WIDTH CHANGE 0410
hereby affirm that there is a construction lending agency for RONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). DE
L. GOQ0-0017 f 7% 1/96
Lender's Name. p
$ ¢ LDMA Ref. # 7717 1 PM 5:17
Lender's Address . Fee$ Permit FeeI certify that I have read this application and state that the Issuance Fee Of LDMA P/C#above information is correct. I agree to comply with all County estigation Fee �5 Q
R ordinances and State laws relating to building construction, Total Fee /!/ O% LDMA Perm. #
< and hreby uthorize representatives of this County to enter
upon a ove-mentione operty for inspection purposes.
a
_ � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date