HomeMy Public PortalAbout6029ALESSANDRO AVE_Building (4) " WORKERS'COMPENSATION DECLARATION
eu�e qfeni to oft, acertifats of Workers' Compensation Insurance, APPLICATION FORBUILDING PERMIT
or6-certifted
cppy 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
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion deportment. ADDRESS (22_ C (e e l
Date Applicant CITY 7e--,,,Q1e-- r-.flv ZIP /ry ( LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT 3 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 GE PARCEL
rp STEL. e� USE Z NE MAP
OWNER !�U' OVOL(� Nr')tiC. �646L- ";S7
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any manner , a. SPECIAL
so as to be ome subject to the Wo Co ensat.on Laws. ADDRESS // 6ta .9 ! CONDITIONS O
Date lf;t Applican CITY �.s� {� J ZIP
NOTICE O AP LICANT: If, after making this Certi ate of ARCHITECT OR TEL. DISTRICT GR TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers' ENGINEER NO. CONST. I ZOI�LE U
Compensation provisions of the Labor Code, you must forth- ADDRESS J� iV/ LU
with comply with such provisions or this permit shall be 0-1
TEL. STATISTICAL CLASSIFICA ION APT o CONDO. t
deemed revoked. CONTRACTOR NO.
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
Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. Oel NO.OF / NO.OF CHECK
License Number Lic.Class SIZE z U91STORIE1 FAMILIES ) ONE
VALUATION
I am exempt under Sec.
❑
DESCRIPTION OF WORK �Gi�G� NEW $
Contractor Date ADD ❑ ,yt ❑
_ ALTER
B.&P.C. for this reason ✓ d✓ REPAIR $
Date: USE OI F BLDG. DEMOL ❑ ;29 4 314 A
,EXISignature APPLICANT TEL. FINA # 0 0 0 0 0 ,1
OWNER-BUILDER DECLARATION PRINT Q[ nZ NO. J 7S9 DA 0 1 H 1, 1 3
I hereby affirm that I am exempt from the Contractor's License IF
Low for the following reason (Section 7031.5, Business andADDRESS FINAL
Professions Code): R By 'o o 1 8 1. 1 3 3
BUILDING
I, as owner of the property, or my employees with ADDRESS j)4 2�1 ,—8
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.
❑ I, 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
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 4 /�
m LDMA Ref. #
P.C. Fee$ Permit Fee �f
Lender's Address_
3 I certify that I have read this application and state that the
o Y PP Issuance Fee LDMA P/C N
o above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee (J / LDMA Perm. #i
6 an re authorize representatives of this County to enter
on the ove-coarntioned perty for inspection p rpos s.
`o SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Applican Agent Date