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HomeMy Public PortalAbout5833ALESSANDRO AVE_Building (2) r WORKERS' COMPENSATION DECLARATION I hereaffirm that I have a ce'rti ficate of consent to• insure, wr a certificate of Workers' Compensation Insurance, APPLICATI014 FOR BUILDING PERMIT or 0.c kttified copy thereof (Sec. 3800, Lab. C..) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ElCertified copy is hereby furnished. FOR APPLICANT TO FILL INBUILDING ro ADDRESS ��.r G.�SS/I/✓(7GGO ❑ Certified copy is filed with the county building inspec- gDDRESS 5 -z90-t W�o 4VE tion department. CITY ,• ZIP 17( LOCALITY Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT to X ;� NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR v (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK O PAGE �� PARCEL hundred dollars ($100) or less.) �j ,� /-� � TEL. USE ZONE MAP �� ' OWNER!"QA�r'v��G�� �I N .B�J�� �Y7 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 �O.hN.Q cx ab-0 Lr� �l CONDITIONS CL soas to become subject to the Workers Compensation Laws.. O CITY ZIP Date Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY CONST.. � NE C e17t— Exemption, you should become subject to the Workers' / �( / f W Compensation provisions of the Labor Code, you must forth-- L79 with comply with such provisions or this permit shall be �" r TEL �aaS--IF!'Z STATISTICAL CLASSIFICATION APT. CONDO. N ��ii t� `, ( Z deemed revoked. CONTRACTO l e�6-d t°Y47 NO._P7/ CLASS NO.�DWELL. UNITS LICENSED CONTRACTORS DECLARATION LIC. 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 �_ PG VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic.'Closs SIZE © STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTIONl3 � OF WORK NEW ❑ $ ��/ ❑I am exempt under Sec. pQVC c /ou{✓1 aira 8,. ADD ► ALTER ❑ B.&P.C. for this reason ccs( .)r., ^Cd �lo �Y3�tYVt34✓l REPAIR ❑ $ o Date: US OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT• �? "- TEL. ra; f �, FINAL OWNER-BUILDER DECLARATION (PRINT) 4",FI CT-H J N o! Y QQ DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS C e QS qFINAL Pro scions Code): PRESENT By U LDING I, as owner of the property, or my employees with ADDRESS _JJ wages as their sole compensation,will do the work and G —:-.- the structure is not intended or offered for sale(Section tADDRE Y ��_ / 's:'s_;' 7s„i 1 lgc 7044, Business and Professions Code.) G TEL. I, as owner of the property, am exclusively contracting CTOR NO. fla y z ¢1 4 t with licensed contractors to construct the project (Sec- S v G / l�-`I'�'L ''�" � tion 7044, Business and Professions Code.) ''!•G - __ IRED TOTAL SETBACK FROM EXIST. t It _ CONSTRUCTION LENDING AGENCY ACK YARD HWY PROP. LINE WIDTH C'� ` �`.�y t hereby affirm that there is a construction lending agency for T the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). ¢� }y Lender's Name. LDMA Ref. # r o - - 7 f r e $ .eJ Permit Fee , v4 +I i:iLender's Address�tM �-F j. 5symch-,1 certify that I have read this application and state that the Issuance Fee �J LDMA P/C ttabove information is correct. I agree to comply with all County ation Feeordinances and State laws relating To building constructionTotal Fee O • `” LDMA Perm. N a and hereby authorize representatives of this County to enter upo the above-mentione pec ion purposes. {{ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of plicant or Agent Date