HomeMy Public PortalAbout5833ALESSANDRO AVE_Building (3) WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) i`
COUNTY OF LOS ANGELES 'a, BUILDING AND SAFETY
Policy No. Company
❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING n`
PY Y ADDRESS �j L SSS •{Ifs
❑ Certified copy is filed with the county building inspec- BUILDING } S` ,�. Q ��
tion department. ADDRESS //J,�, /� ,(A0! C. G 7 O
CITY (J� city ZIP o" LOCALITY
Date Applicant NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT L NOW ON LOT CROSS ST. C(
COMPENSATION INSURANCE / ASSESSOR j7r
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK o✓ PAGE !:502d PARCEL
hundred dollars ($100) or less.) A� TEL.
OWNER anclto /-(Q1 h NO. �" > USE ZONE NO
D o2(0
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS � SPECIAL a}..
so as to become subject to the Workers' Compensation Laws. CONDITIONS O
CITY " ZIP U
Date---- Applicant. ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
CONST. ONE ►-
Exemption, you should become subject to the Workers' O� _� ` / � U
Compensation provisions of the Labor Code, you.must forth- ADDRESS oe V �LL a
with comply with such provisions or this permit shall be D T` r� T L. STATISTICAL CLASSIFI ATION APT. CONDO. Z
deemed revoked. CONTRACTOR 1p �Gj1 /LY _
LICENSED CONTRACTORS DECLARATION y,�- LIC. CLASS NO.�DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �V �-� NO.
(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 PG VALIDATION
SQ. FT. O. OF NO. OF CHECK
License Number Lic. Class SIZE Y STORIES FAMILIES — ONE
VALUATION
ContractorDate DESCRIPTION OF WORK NEW ❑ $ /r O b
ADD 1:1f ►
❑I am exempt under Sec. _ Q
ALTER ❑
B.&P.C. for this reason $
REPAIR ❑
Date: U OF
EX G BLDG. DEMOL ?❑
Signature APPLICANT
OWNER-BUILDER DECLARATION (PRINT) Gli/ , J 'NO. 71 FINAL
I hereby affirm that I am exempt from the Contractor's License DATE
Law for the following reason (Section 7031.5,Business and ADDRESS O OJR—
FINAL
Prryofosts�ionsCode): PRESENT By ;•/ ..
Lf�J I, as owner of theproperty, or m em to employees with BUILDING Q, ¢ S, A-_._.I ,�
Y P Y ADDRESS •r-,_,�.
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 (,c3 t„'t./v
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 G S_
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE,
P.L. r _..
Lender's Name. CHECK 47 ,
LDMA Ref. #
n
P.C. Fee$ ' Permit Fee t,;ii)a•:Uw ;,I
Lender's Address �j
0 1 certify that I have read this application and state that the Issuance Fee o� J LDMA P/C#
0
8 above information is correct. I agree to comply with all County Investigation Fee _.;)Rj'._t ri-j'
d ordinances and State laws relating to building construction, Total Fee LDMA Perm. # 1 rf Wit•'+
and hereby authorize representative of this County to enter {t.
upon the abov -meaiiette perty for inspection purposes.
a N
�v A,4sf14 : �- 7�` =9Y SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Ap n or Agent Date