HomeMy Public PortalAbout6029ALESSANDRO AVE_Building (3) WORKER$' COMPENSATION DECLARATION _
I hereby'of, that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT u
or a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ILS:
ADDRESS
ElCertified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS c� L �
Date Applicant CITY 'IL ZIP / LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' �p NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT C� �{ 13 NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK P PARCEL
I certify that in the performance of the work for which this OWNER/4"ipbD TEL.VA q_- G Z. �'t��/ USEMAP
NE NO.
permit is issued, I shall not employ any person in any manner SPECIAL
SPECIAL
so as to become subject to the Work omp sation L ws. ADDRESS 0 � � CONDITIONS 0
L !� CITY �f ZIP
Date Applicant �
ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after 111)
making this CerTifi a of DISTRICT G UP TYPE FIRE PROLE ED BY O ZONE
Exemption, you should become subject to the Workers' ENGINEER NO. .i ��� CONST.
/ V
Compensation provisions of the Labor Code, you must forth- �\//
ADDRESS W
with comply with such provisions or this permit shall be am
deemed revoked. CONTRACTOR NO. STATISTICAL CLASSIFI ATION APT. CO (n
Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS i r
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
Professions Code, and my license is in full force and effect. CITY CLASS VALIDATION
SO. FT. NO. OF NO.OF CHECK BK. PG.
License Number Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date
DESCRIPTION OF WORK O U� cJG� NEW 1:1❑
E] s
ADD I am exempt under Sec. ❑
ALTER loop
B.BP.C. for this reason REPAIR ❑ $
Date: USE OF DEMOL
EXISTING BLDG. # 9 4 5
Signature APPLICANTTEL• FINAL /-
OWNER-BUILDER DECLARATION PRINT v G+w�-NO. 2017 / DATE 1!J r/r!e I o 0 6 Q 5 Q
I hereby affirm that I am exempt from the Contractor's License �� / ��,G,'s9 /O Q 5
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL 0:a 0
Pr fessions Code): PR
BUILDING
ISENT
By 0 4,2 `8
A7I, 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.
1, 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 F
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
P.L.
Lender's Name
P.C. Fee$ Permit Fee d Qa LD MA Ref. #
m Lender's Address �] `_
1 certify that I have read this application and state that the Issuance Fee v i J LDMA P/C#
g above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee
d LDMA Perm. #
and h authorize repress fives of this County to enter
m uo the ova- ntioned party for inspection pur oses.
2� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Appl iconf or Agent date