HomeMy Public PortalAbout6029ALESSANDRO AVE_Building (5) WORKERS'COMPENSATION DECLARATION
-herebyp a#firm-'that I have a certificate of consent to self_ APPLICATION FOR BUILDING PERMIT
insure, orcertificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
E] Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS �p
Date Applicant CITY ✓^ ZIP % LOCALITY `
CERTIFICATE OVEXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT 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 PAGE PARCEL
I certify that in the performance of the work for which this OWNER 01_ C 1�.1ZIL. L7�� SE Z NE OP
permit is issued, I shall not employ any person in any manner / SPECIALt
so as to become subject to the Work 'Com nsat' n Laws. ADDRESS ��' "` CONDITIONS 0.
�L CITY ZIP
U
Date Applicant LL'
NOTICE TO APPLICANT: If, after ki
ang this C ificate of ARCHITECT OR TEL. DISTRICT GRUP FIRE PR ESSED BY O
Exemption, you should become subject to the Workers' �
ENGINEER NO. COCONST. ZO E V
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall bea:
deemed revoked. CONTRACTOR O STATISTICAL CLASSIFICATION APT. CONDO. fn
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 andLIC. SEWER MAP
Professions Code, and my license is in full force and effect. CITY / CLASSBK VALIDATION
SQ. FT. NO. OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
DESCRIPTION OF WORK NEW $
/t/�
ContrVALUATION
ADD actor Date ❑ d V O
❑ I am exempt under Sec. �- ❑
�► ALTER
B.BP.C. for this reason REPAIR ❑ $
Dote: USE EXISTOING BLDG. DEMOL ❑ # 0 0 0 0
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT NO. DATE ° ° 4 0 5 Q
1 hereby affirm that I am exempt from the Contractor's License o`o o 4 Q
Pr =
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
of. ions Code): PRESENT By O �.� b y
BUILDING
I, 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.
❑ 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).
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK F
SET BACK 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
�1 LDMA Ref. #
m P.C. Fee$ Permit Fee ' (�
Lender's Address _
I certify that I have read this application and state that the Issuance Fee D S LDMA P/C#
o above information is correct. I agree to comply with all County Investigation Fee CC
0 ordinances and State laws relating to building construction, Total Fee J LDMA Perm. #
6 and hereby authorize representatives of this County to enter
m upon thea meriti :edKperty for inspection purposes.
m
SEE REVERSE FOR EXPLANATORY LANGUAGE
n Signature of Applicant o^gDate