HomeMy Public PortalAbout5823ALESSANDRO AVE_Building WORKES',COMFsWSATION DECLARATION
I hs,reby offirm•.that I have a certificate of consent to self
ensure;`or a certificate of Workers',Compensation Insurance, APPLICATION FOR BUILDING PERMIT ..
.off a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No a Company Q S.n�
BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
DateR axe?5 Applicant O CITY ZIP LOCALITY
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WO <ERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed'if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL. ^
OWNER NO �(`. USE ONE OP
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 S�a� � CONDITIONS
so as to become subject to the Workers' Compensation Laws. O
CL
CITY C ZIP ��EU
Date Applicant ARCHITECT O TEL
NOTICE TO APPLICANT: If, after making this Certificate of +t4@"4EE�R DISTRICT GROUP TYPE FIRE P SED BY
CONS ZONE
Exemption, you should become subject to the Workers' �y,� /�'� /�/ �U
\ Compensation provisions of the Labor Code, you must forth- ADDRESS XZ `,1 C/" (/ �� 0-
with comply with such provisions or this permit shall 'be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. �, / _
{{1�� LICENSED CONTRACTORS DECLARATION ` UC. CLASS NO.�DWELL. UNITS
y' I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS S y \ NO.S
(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 2 'q_C� CLASS �� /3 Li VALIDATION
L SQ. FT NO. OF NO. OF iCHECK BK
/v License Number CJ � _Lic. Class��1 SIZE STORIES y FAMILIES ONE
4 n �•��� �-��.�, VALUATION
Contractor4�j�+ - �10►y Date KS]R� DESCRIPTION OF WORK NEW ❑ s,,z fv/ ®D D
ElI am exempt under Sec. ®/�() ADD pop-
ALTER ALTER ❑
B.&P.C. for this reason REPA
EXISTING
❑ $
Date: USE OF ❑
EXISTING BLDG. DEMOL
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT) NO.
DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT By
'' ACCT.T
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and su 273.75
the structure is not intended or offered for sale(Section
LOCALITY ► ""�
7044, Business and Professions Code.) MOVING TEL. 1 ITEMS
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. y
with licensed contractors to construct the project (Sec.- ADDRESS TOTAL 273. 75
� • .
tion 7044, Business and Professions Code.) REQUIRED f 7�.�r
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROPAINEFROM WIDTH CHECK 7
I hereby affirm that there is a construction lending agency for FRONT CHANGE .00
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.).. SIDE �y
�V �J1 i1J 2 G
Lender's Name, P.L. 17 ..9�V5360
0 1 Ai(+.�p�� 8:351
�
P.C. Fee$ Permit Fee
,�r�7 LDMA Ref. #
� Lender's Address 17
o I certify that I have read this application and state that the Issuance Fee LDMA P/C#
0
8 above information is correct. I agree to comply with all County Investigation Fee
N ordinancea laws to building construction, Total Fee � LDMA Perm. #
a and Eby authorize r pr es of this County to enter
on the ab a-me n rty for inspectio urposes. ;
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Applicant or Agent Date