HomeMy Public PortalAbout5827ALESSANDRO AVE_Building (2) 860000. LA
WORKERS'COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self APPLICATION FOR :B U•I L D I N G PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) I - •
IV85-225 I Fremont Indernnit COUNTY OF LOS ANGELES BUILDING,AND SAFETY
Policy.No. C%4npany y
El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING 55r
ADDRESS D
Certified copy is filed with the county building inspec- BUILDING Attessandro
tion department. ADDRESS M-•-If-a=l-d--J-aL-ics=
Date 1/6/86 ApplicontVirgin Roof, Co. CITY Temple City ZIP LOCALITY i
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one - - - ASSESSOR`
hundred dollars ($100)or less,) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. USE NE MAP
OWNER Mrs. Harold Jackson No. d-7
I certify'that in the performance of the work for which this NO. 216 >_
permit is issued, I shall not employ any person in any manner 55827 Allessandro SPECIAL d
so as to become,subject to the Workers'Compensation Laws.
ADDRES - CONDITIONS 00
.' .CITY Temple. City ZIP oc
Date Applicant ARCHITECT OR TEL.
DISTRICT GROUP. TYPE FIRE PROC SED BY
NOTICE -TO APPLICANT' If, after making this' Certificate of CONST. ZONE 0
ENGINEER NO.
Exemption, you should become subject to the. Workers'
LU
Compensation provisions of the.Labor Code, you must forth- ADDRESS l(J/ P.5 /;) ®-
with comply with such provisions or,this permit shall be in
TEL. STATISTICAL CLASSIFICATION APT. ONDO. in
deemed revoked. CONTRACTOR Vir in Roof CO NO. 28]—O5O _
LICENSED CONTRACTORS DECLARATION - pp .Q BOX J LIC. 160650 CLASS NO. 2'� 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 and SEWER MAP
( g ) San Gabriel CL C39
Professions Code, and my license is in full force and effect. CITY CLASSBK VALIDATION
SQ. FT. NO.OF NO. OF CHECK
160650' ' . C39 SIZE STORIES one FAMILIES ONE
License Number Lic.Class VALUATION
❑
Contractor Vi'rg Dote in'.ROOf CO 1/6/86 DESCRIPTION OF WORK Re-roof. house with NEW $ 1665.00
ADD ❑
❑ I am exempt under Sec. Class A fiberglass shingles, ❑ ,
ALTER
B.BP.C."for this reason 16 s s. Flat area with #30, 66 1 EPAIR ❑ $ ;23924A
Date:. USEOF and 6672. 4 s uares
EXISTING BLDG. DEMOL ❑ # 0 0 0 0_o
APPLICANT TEL.
ix
Signature -�� FINAL
PRINT) Vir in Roof Co No. 287-0507 ������ I a o49,88
OWNER-BUILDER DECLARATION ..DATE-
I hereby affirm that I am exempt from the Contractor's License - ADDRESS P O BOX J, San Gabriel-'91778 FINA ° °'° 4 9'8 8
Law for the following reason (Section 7031.5, Business and
Professions Code)`, PRESENT - BY' 1
BUILDING Q 1,2 4-8 6
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and '
the'structure is not intended or offered for sale(Section LOCALITY ,
7044, Business and Professions Code). 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.
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. - - - -•'
(Sec. 3097, Civ. C.). SIDE
m P.L.
Lender's Name
mLDMA Ref. #
-- - -
P.C. Fee$- •- - Permit Fee 39.38 _ - .
Lender's Address '
I certify that I have read this application and state that the Issuance Fee- - 10.50 LDMA P/C#-
a above information is correct. I agree to comply with all County Investigation Fee
$ ordinances and State laws relating to building construction, Total Fee 49-88 LDMA Perm. #
u andeby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
o
a SEEREVERSE FOR EXPLANATORY LANGUAGE '
o ,
nature of Applicant or Agent Date -- - - - - - - - - •�°