HomeMy Public PortalAbout6018ALESSANDRO AVE_Building (2) ^J^ WORO�NSATION�DECLR,RAiIOtY'' ivr
I hereby affirmA �avc� a certificate of c ns nt toy elf e
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nsure or a certificate of Workers tCompensatTon�msurace t' e s-YaYy `� AT I®�W� }®tR ®' - PERMIT
oris certified copy thereof (Sec 3800 Lab C )� - �' d-4 L r zf�,' ^L. ti 4 t `, i " a _
�_ � t Maxx rx f COUNTY OF LOS ANGELES P =e �b BUILDING AND SAFETYr
Policy No w Company,
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN 1 BUILDING � Q �i
ADDRESS e � 1 U
❑ Certified copy'is filed with the countyibuildmg inspec BUILDING
tion`department ADDRESS Q
^ ' IleV� V
Date dApplicant CITY ZIP �/ LOCALITY` rt c
/ O OF BLDGS J1 NEAREST
CERTIFICATE OF EXEMPTION FROMtWORKERS SIZE OF LOT NOW ON LOT CROSS ST
w - _ COMPENSATION INSURANCE _
(This section need not be completed if the peimit is for one ` 4 ASSESSOR'S `
TRACT BLOCK -A LOT NO MAP BOOK GE PARCEL
" hundred dollars ($100)or less.), �
r - - // TEL USE NE MAP� > q
1 certify`that in the performance of the work for which this OWNER 4 �O Y NO
permit is issued I shall not employ any person in any manner p r` - SPECIALi
so as toibecome subject to the Workers,Compensation Laws ADDRESS - CONDITIONS+ s 4
CIT
n , r ZIP Q' D
DateL� � Applica
U
ARCHITECT OR TEL '
NOTICE TO APPLICANT ,If after making t ertificate o a DISTRICT GR UP TYPE FIRE PROCESSED BY O
ENGINEER NO
Exemption you should ;become subject to the Workers _ ` >~^/,C/ CONST ZONE A U
Compensation provisions of the Labor Code you must forth x J !/if '> ✓ -
with comply with such,provisions or this permit shall be a ADDRESS _ Y CL
deemed revoked d 4 by is CONTRACTOR ; NO' , STATISTICAL CLASSIFICATION APTL-COIN:IIIIIIIIIIIIIIJ CA
Z
LICENSED CONTRACTORS DECLARATION LIC _ CLASS NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS - ° NO
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Y
k Professions Code and my license is in full force and effect CITY s CLASS" x BK r VALIDATION
PG
SQ FT NO OF NO OF CHECK
License Number Lic Class SIZE p°� STORIES FAMILIES ONE
J , ❑ VALUATION t` i M ;27492A
Contractor Date
{� DESCRIPTION OF WORK , NEW ✓.' �
ADD $ ® # o • o • 2'3
r ' '❑ I am exempt under Sec+ i �. - ❑ T
ALTER
B&P C for this reason REPAIR ❑ S �vo ei� `• 293.90
p ' USE OF DEMOLr ❑ r • e 2 9 3.,9 040:
Date EXISTING BLDG �� -
r a APPLICANT gJad TEL LD L c 67 7 !-8 7
Signature r FINAL
'OWNER BUILDER DECLARATION PRINT NO _ DATE 7 8 U b A'
I hereby affirm that I am exempt from the Contractor s License 9 to 0 0 ;
Law for the following,reason (Section 7031 5 Business and a ADDRESS G FINAL �f# • • 2 3
Profe tons Code) o r PRESENT, , - By - o o • �` L),
r BUILDING � ,.. c
_ t T I t as owner of-the property or my employees with s ADDRESS , \ Y 9 0 -
wages as their sole compensation will do the work and T r e` ` * t T�� e a
the structure is not intended or offered for sale(Section [AR
LITY
7044 Business and Professions Code) NG TEL `� }�'4) kj �1.4,5 s
❑ s 1 as owner of the property am exclusively contracting RACTOR a NO
W
ith licensed contractors to construct the project (Sec '
1 tion 7044 Business and Professions Code) r ESS § ` tti • ci,
`^ CONSTRUCTION LENDING AGENCY UIRED YARD HWY TOTAL SETBACK3 � €� ' qt,'� r 0 9 0 4 8 `
BACK PROP LINE WIDTH
I hereby affirm that there`1s a construction lending agency for NT
-the performance of the work for which this permit isyissued
(Sec 3097 Gv C ) a E
Lenders Name
70 LDMA Ref #
m Lender s Address ) - ee S Permit Fee I certify that I have read this application and state that the Issuance Fee J V MA P/C Aabove information is correct I agree to comply with all County s Investigation Fee '
0 ordinances and State jaws relating to building construction g ' Total Fee
`and hereby authorize representatives of this County to enter LDMA Perm q ! M1
u the above men ed roperty for inspection purposes
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m
-7-17 ,87 SEEIREVERSE FOR EXPLANATORY LANGUAGE
ri Signature of Applicant or Agent Date
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