HomeMy Public PortalAbout5827ALESSANDRO AVE_Building (3) WORKERS' COMPENSATION DECLARATION
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APPLICATION FOR BUILDING PERMIT
r'hereby
dreracertifcate of WorkersCompensation consentu�
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING Q� C/C�C�L�.J�✓./G�ZD
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING 5¢z�7 A�SSANp�(� � �
tion department. ADDRESSrxAuu / i1�1 '7
Date Applicant CITY EMpLr- CI'C ZIP 1 / 90 LOCALITYNO. 5F BLDGS.
CX'CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 50' 2001 NOW ON LOT UITE CROSSSST.
COMPENSATION INSURANCE y//� ASSESSOR
(This section need not be completed if the permit is for one TRACT (I BLOCK LOT NO. / ✓7- MAP BOOK PAGE ��'� PARCEL�4
hundred dollars ($100) or less.) TEL. Q p '9 2 USE ZONE MAP
OWNER EflR� j_IAN NO.(lI0 �OsVI
I certify that in the performance of the work for which thisNO
e/ .
permit is issued, I shall not employ any person in any manner ADDRESS / L 7UAIAS DKO �— SPECIAL d
S_
CONDITIONS
so as to become subject to the Workers' Compensation Laws. 0
CITY EMLE clrZ ZIP 9/7So U
Date Applicant ARCHITECT OR TEL. tY
ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY 0
NOTICE TO APPLICANT: If; after making this Certificate of CONST. Z
ONE
Exemption, you should become subject to the Workers' ✓ U
Compensation provisions of the Labor Code, you must forth- ADDRESS �j0 a
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
mmmlllil
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK G PG Ag$;"� VALIDATION
SQ. FT. NO. OF / NO. OF r CHECK
License Number Lic. Class SIZE STORIES FAMILIES ONE
CU �Ns7 A IJOBR VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑ $ /POO,
[X c1o;E AXIMA14 Poet O�A11A* ADD ❑ ,
• ❑I am exempt under Sec.
B.&P.C. for this reason (3) &,%#Yfi: ALTER
REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT//��yy 4(PRINT) TEL.NO. /�
l7Cfl �, Lr �(8 � 3/S� FINAL
OWNER-BUILDER DECLARATION DAT
I herebyaffirm that I am exempt from the Contractor's License 4s/ 5
Law fothe following reason(Section 7031.5, Business and ADDRESSq37/p �u� DR'/ 7' FINAL
Professions Code): PRESENT By
BUILD
ING
❑ I, as owner of the property, or my employees with A D D R ESS i�[_i_.t =a
wages as their sole compensation,will do the work and
cn
the structure is not intended or offered for'sale(Section LOCALITY , ._�-a i_7
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 '•;Ham'.;, -_• -
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.
F P
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name. _.
m LDMA Ref. # (ii S}f;_ -t's.is fi_ _:
P.C. Fee$ Permit Fee _
Lender's Address 3 s (? _
1 certify that I have read this application and state that the Issuance Fee � LDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Feeyf
R ordinances and State laws relating to building construction, Total Fee 4fJ i LDMA Perm. #
a and hereb 'ze representatives of this County to enter
upon above entione /operty for inspectio p poses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ant or Agent Date