HomeMy Public PortalAbout6009ALESSANDRO AVE_Building (3) t
WORKERS COMPENSATION DECLARATION
hereby affirm that I have a certificate of congerilIn—lur Selft, r APPLICATION FOR BUILDING PERMIT
insure or a certificate of Workers Compensation Insurance +
or a certified copy thereof (Sec 3800 Lab C )
� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company _
5` Certified copy is hereby furnished ' FOR APPLICANT TO FILL IN ADDRESS 6, o v A.)BUILDING �,L t gNn
Certified copy is filed with the county building inspec r BUILDING (tt �] m
tion department ADDRESS N 12�i �l(J LOCALITY ` L�
„ /� /� X70 NEAREST
Date Applicant CITY — C I T� ZIP "! I� v CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS 0'^ NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT �3� V NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one yy � USE Z4 NE MAP
hundred dollars ($100)or less ) _ TRACT BLOCK LOT NO OV 1 NO
r TEL /n� (� SPECIAL }
I certify that in the performance of the work for which this OWNERJO &41W I— 1. L NO d D37d CONDITIONS �
D ICT GR UP TYPE FIRE PROCE E BY O
permit is issued I shall not employ any person in any manner CO ZONE V
so as to become subject to the Workers Compensation Laws ADDRESS Ll=SS Q1 �)� :� *P!�_)
Date Applicant i CITY L- / / ZIP / STATISTICAL CLASSIFICATION APT CONDO 0
NOTICE TO APPLICANT If after makin this Certificate of ARCHITECT OR I. TEL n
Exemption you should become subject to the Workers ENGINEER f'~ NO V CLASS NO_DWELL UNITS a
Compensation provisions of the Labor Code you must forth ADDRESS V 1 L =�� SEWER MAP Z
with comply with such provisions or this permit shall be {
TEL
deemed revoked CONTRACTOR NO BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION LIC /
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO J VALUATION-
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code and my license is in full force and effect CITY CLASS $ b d 0 ,
SQ FT /� NO OF NO OF CHECK
License Number Lic Class SIZE ^ L/ STORIES FAMILIES ONE
$
DESCRIPTION OF WORK NEW
Contractor Date t
I am exempt under Sec �) ADD
ALTER FINAL `�
B 8P C for this reason2 . � REPAIR DATE S V
USE OF ❑ FI ` 2 6� 1 A
Date EXISTING BLDG DEMOL
nature APPLICANT y p TEL r� ? p B ° ° ° ° ° 1
OWNER BUILDER DECLARATION PRINT EN !� / IL TN oC J�Q
I hereby affirm that I am exempt from the Contractor s License IC 2,o25613
Law for the followingreason Section 7031 5 Business and ADDRESS L
(
RfssionsCode) 2 5 6 1 3
I BUILDING t
I as owner of the property or my employees with ADDRESS 0,608-83
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
C3I 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)
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
the performance of the work for which this permit is issued P L
(Sec 3097 Civ C ) SIDE
PL
Lender s Name
Lender s Address PC Fee$ Permit Fee pZ
I certify that I have read this application and state that the Issuance Fee
above information is correct I agree to comply with all CountyInvestigation Fee
ordinances and State laws relating to building construction Total Fee
d and hereby authorize representatives of this County to enter + t
upon the above mentioned property for inspection purposes r t
J/tL �DfA_ /z - J0_J?3 SEE REVERSE FOR EXPLANATORY LANGUAGE
n Signature of Applicant or Agent Date ®s
e