HomeMy Public PortalAbout5926ALESSANDRO AVE_Building (2) ZQMPENSATION DECLAR ,
have a certifid1A' T14'&N�catea selfompe rance, APP
of Workers'CF•®R BUILDING PERMIT
e
0r'o c.:r., copy thereof (Sec. 3800 Lai
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company_,
Ef Certified copy is hereby furnished. FOR APPLICANT TO FI11 LL IN BUILDING
ADDRESS
Certified copy is filed with the county building inspec- 'BUIL DING
tion department. ADDRESS
Date Applicant CITY 0 ZIP LOCALITY
6RTIFICATE OF EXEMPTION FROM WORKERS' 'Na.OF BLDGS. NEAREST
r COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. Wfm
(?This section need not be completed if the permit is for one /'.. ASSESSOR
hundred dollars($100)or less.) TRACT (R) BLOCK LOT NO. MAp BOOK JPA(VE PARCEL
TEL. USE NE MAP
I certify that in the performance of the work for which this OWNER �G r NO. NO.
permit is issued, I shall not employ any person in any mannerZAR y ,may Q2) SPECIAL O
so as to become subject to the Workers' o ensation Laws. ADDRESS YD 6 I0AJATCJ �✓ CONDITIONS
Date_q— — , Applicant a r CITY ZIP �
ARCHITECT TEL.
NOTICE TO APPLICANT: If, after making this Certific of DISTRICT OU TYPE FIRE SSED BY O
ENGINEE (/� O.
Exemption, you should become subject to the W rkers' CONST.
j ZE U
Compensation provisions of the Labor Code, you must forth- ADDRESSa���I tJG r1r. �. v W.
with comply with such provisions or th' per it shall be tS.
0
deemed revoked. d�G TEL. STATISTICAL C IFN
C ON APT. �ONDO.
CONTRACTOR• ,` /v NO. % z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.T 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 LIC SEWER MAP .
Professions Code, and my license is in full force and effect. CITY 44CLASS J VALIDATION
SQ. NO.OF NO.OF dp CHECK BK. !r PG.
License Number lic.Class SIZ STORIES LFAMILIE",fjr ONE
VALUATION -
DESCRIPTION OF WORK NEW - 8 43,'1 A
Contractor Date
ADD $
I am exempt under Sec. V4f � 1;q 7 5 6
C, ALTER ❑
1. 0
B.BP.C. for this reason USE OF REPAIR $ 56 3/ QD DEMOL � ( 2 9 4 5 8 A 25-87
Date: EXISTING BLDG.. r��i�i�i ❑
Signature APPLICANT /� TEL. # 0 0 0 0 23
OWNER-BUILDER DECLARATION PRIM !Z PNe NO. Z FINAL
1 hereby affirm that I am exempt from the Contractor's License ���,/ _ ,Q DATE 0 3 3 0.19
Low for the following reason (Section 7031.5, Business and ADDRESSkW1 06 1� 1 4 . FINAL o 0330, 195
Professions Code): PRE ENTMoo By 04.26-88
❑ BUILDING .�
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.
1,as owner of the property, am exclusive) contracting CONTRACTOR NO. r q
P P Y, Y 9 #��� ��,�,�P
with licensed contractors to construct theproject (Sec- ADDRESS .1289275
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD •HWY.• PROP. LINE WIDTH o2,89275'.
I hereby affirm that there is a construction lending agency for FRONT "1 0 (1 2 6-88
the performance of the work for which this permit is issued P.L. 01 :
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name !U Ul �
Rx n LDMA Ref. #
m P.C. FeeS," r PermtFee
Lender's Address
a I certify that I have read this application and state that the f �,S�
a fY PP Issuance Fee LDMA P/C#
g above information is correct. I agree to comply with all County Investi atio Fee —J
0 ordinances and State laws relating to building construction, g t L9
R and hereby authorize representatives of this County to enter = Total Fee r/ LAMA perm. q
upon the above-mentioned property for inspection purposes.
a
m r 41— C—_ fa SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Ago,,/
g Date