HomeMy Public PortalAbout5926ALESSANDRO AVE_Building (3) i I WORKERS' COMPENSATION DECLARATION
•'' %I here �insure,boraa certif catte of Worke s' Comipensat on eInsuran of APPLICATION . FOR BUILDING PERMIT
Or a certified copy thereof (Sec. 3800, L C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nb_ ADDRESS
F3 copy ZGG Company �Rlk6
rBUILDING
tified cois hereby furnished. FOR APPLICANT TO FILL IN
� , v
L Certified copy is filed with the county building inspec- BUILDIN
RES ,ZS
tion department. ADD , j2
Dated_17_ ApPlicanT CITY T L� G ZIP LOCALITY
O. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK I LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) OWNER ' TEL. USE N MAP �� J
G NO. NO.
I certify that in the performance of the work for which this C
permit is issued, I shall not employ any person in any mannerSPECIAL >_
ADDRESS 9 YQ C t(d A,,A CONDITIONS 0-
so as to become subject to the Workers' Compensation Laws. 1O
CITY �� G� ZIP 6 U
Date Applicant ARCHITECT OR TEL. DIST - GROUP TYPE FIRE P O SED �
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CO NE
Exemption, you.should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS �� 0-
with
with comply with such provisions or this permit shall be TEL S TISTICAL CLAS IFI TION APT CONDO. to
deemed revoked: �ift7�' Nd F R g N •�93 Z
LICENSED CONTRACTORS DECLARATION L LIC. CLASS NO. _DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 � �76�' SPA/K�O. TW",/
6
(commencing with Section of Division 3 of the Business � �'� �=/ _
and Professions Code,and myy license
ffLIC. SEWER MAP
license is in full force and effect. CLASS BK PG VALIDATION
U �+ S NO. OF NO. OF CHECK - 26License Number 7 7407 6c. Class ` �� SI STORIES FAMILIES ONE
� D VALUATION A
Contractor Date 7^ 6 DESCRIPTION OF WORK NEW � ACCT•T
E]1 am exempt under Sec. �/t� P� t^ ADD 0 $ao ��. , 3307 iv�t.0
B.&P.C. for this reason ALTER El ITEMS
USE OF O REPAIR ❑ $
Date:' EXISTING BLDG. DEMOL ElT�Nf AL 184
Signature APPLI T T CHECK
FINAL
(P 6 N "C Z.f
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License DATE CHANGE ,[If:
Law for the following reason (Section 7031.5, Business and �' FINAL
Professions Code): PRESENT 8
❑ I, as owner of the property,* or m 'employees with BUILDING 13000-0001 5/i7lf'9
P P Y� YADDRESS
wages as their sole compensation,will do the work and Poo.
�J+t�.$t�t 1 (} }�;
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL. 1
ElCONTRACTOR NO.
I, as owner of the property, am exclusively contracting s
with licensed contractors to construct.the project (Sec- ACCT.ADDRESS 3307 M 00
• tion 7044, Business and Professions Code.) �lt�i. U
REQUIRED TOTAL SETBACK FROM EXIST. TTM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 1 ITEMS
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L. �1_i��L r- r ��
(Sec. 3097, Civ. C.). SIDE +—+-8®
Lender's Name
P.L CHECK 228.00
LDMA Ref. #
P.C. Fee$ Permit Fee CHANGE. . . .I10
Lender's Address
0 1 certify that I have read this application and state that the Issuance Fee v TDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee' O
0000_0001 6/27/39
R ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
a and hereby authorize representatives-of this County to enter 47(-5 1 AM 9;5-7
upon th a ve-m ti ned property for inspection purposes.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature c Ap i ant or Agent