HomeMy Public PortalAbout6009ALESSANDRO AVE_Building (2) WORKERS COMPENSATION DECLARATION
insurehereby
oraa certif canffirm e of Workers srtificate of Compennsat on eInsuran ent to APPLICATION FOR BUILDING PERMIT
ora certified copy thereof (Sec 3800 Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company BUILDING /
❑ Certified copy is hereby furnished FOR APPLICANT
/APPLICANT TO FILL IN ADDRESS Ip�O.cl/U 1t(elSaP7C�ra AV
❑ Certified copy is filed with the county buildirig inspec BUILDING ADDRESS /V /9 �Qtit (Q ��{�1� �f'
tion department /' 1)
Date Applcant CITY / / C� ZIP !�Q LOCALITY i^
NO OF BLDGS _ _ NEAREST r ,
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT CROSS ST W 00a 1"!il �1 C)
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK y LOT NO ��y MAP BOOK PAGE PARCEL
hundred dollars ($100) or less ) OWNER �Yl hold �t �'I TEL NO d _c ,P USE ZONE MAP f
I certify that in the performance of the work for which this / NO
permit
permit is issued I shall not employ any person in any manner ADDRESS bl/V Pt (�SSr7l0�}a!� �l� - �/ SPECIAL 0-
CONDITIONS O
so as to become subject to the Workers/Compensation Laws �-- p r
Will lraud �!Al CITY !e le C% ZIP qt �Q O U
Date ` ApplcanT ARCHITECT OR TEL a DISTRICT G UP TYPE FIRE O ESSED BY O
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO , CONST' ZONE U
Exemption you should become subject to the Workers S �_j W
Compensation provisions of the Labor Code you must forth ADDRESS �v N
with comply with such provisions or this permit shall be TEL z STATISTICAL CLASSIFICATION APT CONDO.. Z
deemed revoked I CONTRACTOR _ NO —
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS
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
and Professions Code and my license is in full force and effect CITY CLASS BK ' PG h VALIDATION
y SQ FT NO OF NO OF CHECK
License Number Lc Class SIZE STORIES / FAMILIES ONE
s� DESCRIPTION OF WORK NEW VALUATION
Contractor Date ❑ s
ADD ❑ALTER ►
El am exempt under Sec
. � I❑
B&P C for this reason REPAIR �J $
Date USE OF
EXISTING BLDG Y DEMOL ❑
Signature APPLICANT TEL FINAL
OWNER BUILDER DECLARATION (PRINT] NO DATE
I hereby affirm that I am exempt from the Contractor s License _
Law for the following reason (Section 7031 5 Business and ADDRESS FINA
P V
Professions Code) PRESENT n By
It
BUILDING O /�r/� ACCT.T
I as owner of the property or my employees with ADDRESS r�
wages as their sole compensation will do the work and //�� 1p����'� ' ■4
the structure is not intended or offered for sale(Section LOCALITY /'Q _ 1.1 , 3307 _49.38
MOVING w TEL
7044 Business and Professions Code )- - 1 ITEMS
❑ I as owner of the property am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec ADDRESS f ; TOTAL 49mai
tion 7044 Business and Professions Code )
11
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT _ o
the performance of the work for which this permit is issued P L t ■��
(Sec 3097 Civ C ) SIDE
r PL
Lender s Name VQ1 - v/ 7ld�f
P C Fee$ µ Permit Fee � i� LDMA Ref #
Lender s Address poll. 4915, - 1 AM 8:39,,
I certify that I have read This application and state that the t r Issuance Fee C/ LDMA P/C#
S above information is correct I agree to comply with all County Investigation Fee
R ordinances and State laws relating to building construction Total Fee LDMA Perm #
a and hereby authorize representatives of this County to enter
upa ththenabbove mento o property for inspect n pur oses
l"��WURG�Gf � 0, r� ��—(Fri SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
t :