HomeMy Public PortalAbout6013ALESSANDRO AVE_Building 7-1
WORKERS COMPENSATION DE+LARATION _ a
hereby affirm that I have a certificatepe of coInsur Insurance
sett ' APPLICATION FOR BUILDING PERMIT
insure or a certificate of Workers Compenstion Insurance or
a certified copy thereof (Sec 3800 Lab C )
355§,mpany Ohio Casualty > - COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoXW018
❑ Certified copy is hereby furnished , - FOR APPLICANT TO FILL IN ADDBUILRING
ESS Q 13 22 e
L�
Certified copy is filed with the county building i sec BUILDING 1
19 tion department American Bui.f hers ADDRESS- 6013�+Allesandro LO LITY
I Date 7/11/83 Applicant CITY em le lilt ZIP ' 91"/80 CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSQR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZO E MAP
hundred dollars ($100)or less ) TRACT BLOCK LOT NO — SPOECIAL �vD
CL
I certify that in the performance of the work for which this OWNER Dillard L• PO3 tO1rr�0 CONDITIONS O
permit is issued I shall not employ any person in any manner DISTRI T GROUP TYPE FIRE PRO SSED BY U
ADDRESS 6013Allesandro � CONST ZONE ad
so as to become subject to the Workers Compensation Laws L S� )/ -3 O
cITYTemple City ZIP 91780 J i (-
Date Applicant , STATISYICAL C ASSIFICATION APT CONDO V
NOTICE TO APPLICANT If after making this Certificate of , ARCHITECT OR TEL
ENGINEER none NO CLASS NO DWELL UNITS
Exemption you should become subject tom he Workers ,y
' Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP Z
with comply with such provisions or this permit shall be er can BUilderS TELPG / r'
deemed revoked CONTRA C NO 287-974 7 VALIDATION
� BK
/ J
LICENSED CONTRACTORS DECLARATION p _
I hereby affirm that I am licensed under provisions of Chapter 9 wt` ADDRESS819k TempleCity BIC, 104325 VALUATION
t (commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code and my license is in full force and effect CITYTemple Cit} CLASSB-1
SQ FT NO OF 1 NO OF y CHECK
LicensbNN b 104325 Lic Class B-1 SIZE STORIES FAMILIES _ ONEon E. Hat-tield $ t
Contrddtba American Bul14ers 7/11/83 DESCRIPTION OF WORK NEW ❑ r
❑ Kitchen Remodel - ADD El
am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer no mens On changes) ALTER Q FINAL /0DATE
acting in my professional capacity (Section 7051 REPAIR
Business and Professions Code) USE OF FINAL
EXISTING BLDG Dwelling , DEMOL ❑ By
Lic or Reg No Date APPLICANT American Bullde � 287-974 V
OWNER BUILDER DECLARATION (PRINT) C/
I hereby affirm that I am exempt from the Contractor s License ADDRESS 5819 Temple City B1Vd.-' -
Law for the following reason (Section 7031 5 Business and
Professions Code) PRESENT -Z 6 0
F1 _ BUILDING _ _ z
I as owner of the property or my employees with ADDRESS 1
wages as their sole compensation will do the work and 1
the structure is not intended or offered for sale(Section LOCALITY o e • e o
7044 Business and Professions Code) MOVING TEL
I as owner of the property am exclusively contracting CONTRACTOR NO 2 0 1 0 6,13
with licensed contractors to construct the project (Sec
tion 7044 Business and Professions Code) _ ADDRESS — o • 1 0 6 1 3 E
REQUIRED TOTAL SETBACK FROM ]EX
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE 0 7 1 3-83
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 ) E SIDE
PL
Lender s Name Y _
m Lender s Address P C Fee$ y }- Permit»Fee S,
> / I certify that I have read this application and state that the Issuance Fee ('j above information is correct I agree to comply with all County Investigation Fee
ordinances and State laws relatin to buildin construction
m g g Total Fee Q �L
and hereby'authorize representatives of this County to enter
on the above m ti d ro ert for inspection purposes t
kmerican �'u1cPe�s y p pj p
By• July 11,1983'' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date 't ®s