HomeMy Public PortalAbout5827ALESSANDRO AVE_Building (4) AWORKERS"COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure or a certificate of Workers Compensation;Insurance, A P P L I CAT I;O N FOR • B l�ISI G' PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF,LOS ANGELES, BUILDING.AND SAFETY
Policy No. Company
BUILDING ElCertifiedcopy is hereby furnished. FOR APPLICANT TO FILL IN J ADDRESS �Xo2 7
ING
❑ Certified-copy is filed with the county building inspec- BUILD ss Z LE�Sq DRo I�,
tion department. AA t
CIN'7�/v/ Lc CIT ZIP 17Q v LOCALITY
Date Applicant % � NO. OF BLDGS. NEAREST 67
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT Q X 2D0 NOW ON LOT Ot✓� CROSS ST.
COMPENSATION INSURANCE //' ASSESSOR /°�
(This section need not be completed if the permit is for one TRACT 5b / BLOCK LOT NO. MAP BOOK r PAGE Oat PARCEL DO
hundred dollars ($1.00) or less.) r t I/ TEL.
OWNER GQ� �L�A,vGT NO. �8?�S 3IS� USE ZONE NO.
6 / f—
I certify that in the performance of the work for which this jJ2 QL�$S�inl.DlpQ SPECIAL (OJ }
permit is issued, I shall not employ any person in any manner ADDRESS o f ' CONDITIONS O
T
CITY l G
so as to become subject to the Workers'Compensation Laws. �M ZIP LE �i�T f1'790 0
Date ApplicantARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after, making this Certificate of ENGINEER NO. CONST. ZONE' F-
Exemption, you should become subject to the Workers' w
Compensation provisions of the Labor Code, you must forth- ADDRESS (J(J -� a
with,comply with such provisions or this permit shall be TEL STATISTICAL.CLASS�ON APT. CONDO. Z
z
deemed revoked. CONTRACTOR � � NO., �y
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO' SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effect. CITY CLASS BK.L PG. VALIDATION
SQ. FT. C NO. OF A� NO. OF CHECK
License Number Lic. Class '
SIZE 5 J STORIES o�"E FAMILIES��� ONE
VALUATION
Contractor Date DESCRIPTION OF WORK(1) ADD *0 H S1 NEW ❑ $ 35 34'3,
❑I am exempt under Sec. BEDROOM.(2) WLLOGATC WATER; ADD ►
ALTER ❑
B.&P.C. for this reason NEATER(3� STNCGO LAUNDR RODN REPAIR ❑ $
Date: USE OF
EXISTING BLDG. siN4L� �'AMII- NQ(1�E DEMOL ❑
Signature APPLICANT /o w /� TEL.
(PRINT). y���7` "� NjD "�0 2 IZ FINAL !� A
OWNER-BUILDER
exemp DECLARATION �2� ALESS�4A)DRO VJ DATE /
I herebyaffirm that 1 am exempt from the Contractor's License ADDRES � � T� C. FINAL
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT _ BY
r:;_;y I ,
❑ I, aBUILDING rs 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 Td.- , ! i
IT
?w;
I, as owner of the property, am exclusively contracting CONTRACTOR NO. _- �-�
with licensed contractors to.construct.the project (Sec- ADDRESS 1~I_51't; a a- N°
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
P.L. _
Lender's Name
//
LDMA-Ref. #
P.C. Fee$ Permit Fee (O�.- 79
Lender's Address `.
0
1 certify that I have read this application and state that the Issuance Fee J LDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee r�
R ordinances and State laws relating to building construction, I Total Fee LDMA Perm. # •. w
a and hereb orize epresen fives of this County to enter
upo above- ntion d erty for inspection purposes.
a �-22-
o SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o 1 or Agent Date. -