HomeMy Public PortalAbout5936ALESSANDRO AVE_Building (2) WORKERS COMPENSATION DECLARATION
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insure bor affcertif carte off Wotke srtCompensat on eInsu ancelf APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company t
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDBUILREING
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Certified copy is filed with the county building inspec BUILDING / f
tion department y ADDRESS 3� I eSSAVUA LOCALITY
Date Applicant It q CITY ��Qf1 NEAREST ` �J ��
Te C ZIP U?0 CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS
NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed ifrthe permit is for one 1 USE ZONE MAP
hundred dollars ($100)or less ) TRACT BLOCK LOT NO NO
TEL / SPECIAL }-
I certify that in the performance'of the work for which this OWNER NO 6� CONDITIONS' m
permit is issued I shall not employ any person in any manner -n ^ DISTRICT GROUP TYPE FIRE PROCESSED BY Q
ADDRESS Tt CONST ZONE
so as to become subject to the Workers Co pensation Laws — �
Date Applicant CITY ZIP STATISTICAL CLASSIFI ATION A CONDO '1 Q
NOTICE O A PLICANT If after making this Certifi to of ARCHITECT OR TEL
Exemption you should become sublect to the Workers ENGINEER NO CLASS NO DWELL UNITS
Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP
with comply with such provisions or this permit shall be TEL _
deemed revoked CONTRACTORNO BK PG VALIDATION t
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION
(commencing with Section 7000)of Division 3 of the Business and i LIC ea
Professions Code and my license is in full force and effect ; CITY CLASS S Ll on o
SQ FT NO OF i NO OF CHECK _
License Number Lc Class SIZE ( C) 7— STORIES ( FAMILIES ONE
r DESCRIPTION OF WORK d NEW ❑ $ 1
Contractor Date ADD ❑
I am exempt under Sec
ALTER ❑ FINAL 1,
B 8P C for this reason REPAIR ❑
DAT '
USE OF
Date EXISTING BLDG _ DEMOL ❑ BIN
Signature APPLICANT TEL
OWNER BUILDER DECLARATION PRINT NO
I hereby affirm that I am exempt from the Contractor s License i t
Law for the following reason (Section 7031 5 Business and ADDRESS
Professions Code) PRESENT
❑ 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
I as owner of the property am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code)
PREQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY YARD HWY PROP LIN WIDTH
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit isissued aPoo
(Sec 3097 Civ C )Lender s Name
Lender s Address Permit Fee`
77,
I certify that I have read this application and state that the Issuance Fee
above information is correct I agree to comply with all County Investigation Fee
ordinances and State jaws relating to building construction Total Fee V
CI and hereby authorize representatives of this County to enter
up he abov mens oned proper t for inspection purposes J r
n
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or gent bate ®s