HomeMy Public PortalAbout6033ALESSANDRO AVE_Building (3) K r- __'WORKERS COMPENSATION DECLARATION 1 M
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insure.5oraa certif carte of Wo ke srtComtpensat on eInsuran elf APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec 3800 Lab C ) ,
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnishedFOR APPLICANT TO FILL IN BUILDING /fes
❑ J
Certified copy is filed with the county building inspec � BUILDING ADDRESS
tion department ADDRESS c _/ S Q
Date 5�� �� Applicant CITY C� L6,C ZIP 4?/7LOCALITY
CERTIFICATE OF EXEMPTION FR M WORKERS 4 NO OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT L 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
TEL USE NE MAP
I certify`that in�the performance of the work for which this OWNER NO i NO
permit is issued I shall not employ any person in any manner ADDRESS-(p0 LFS /Q� f SPECIAL
so as to become subject to the Workers Compensation Laws �, 1 CONDITIONS O
/ �jb
CITY A Q= G/ � ZIP `9/7 r0 U
Date Applicant
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL DISTRICT RJP CONST TYPE FIRE ZONE PROCESSED BY 10
ENGINEER NO S `t ,
Exemption you should become subject to the Workers U v
Compensation provisions of the Labor Code you must forth ADDRESS - W
with comply with such provisions or this permit shall be TEL Q.'
deemed revoked I U STATISTICAL CLASSIFICA ION APT ON N
r CONTRACTOR S / E GD/l►g .NO J A Z
LICENSED CONTRACTORS DECLARATION * LIC CLASS NO DWELL UNITS
-
I hereby affirm that am Icensed under provisions of Chapter 9 ADDRESS /ANT +V/ 0N% 1 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code and my license is in full force and effect CITY4 fir..4l/4 /f DIS CLASS VALIDATION
5-13
SQ FT NO OF _ NO OF CHECK BK PG
License Number J 1 3 q1� Lc Class � SIZE `STORIES FAMILIES ONE
_ 11 .p _ VALUATION
Controctor AIR70511N9 •+x*_rDate- S-'!0 0 � DESCRIPTION OF WORK cPR - i0W NEW ❑ $
ADD ❑
1 am exempt under Sec e7b� AJJJIAV,
C]ALTER
B&P C for this reasonDD REPAIR $
USE OF DEMOL
Date EXISTING BLDG { ❑
Signature APPLICANT TEL FINAL7/,i;
OWNER BUILDER DECLARATION PRINT NO DATE
I hereby affirm that I am exempt from the Contractor s License i ;29576A
Law for the following reason (Section 7031 5 Business and ADDRESS FI # o e e e e
Professions Code) I I PRESENT B❑ o o 4J9 8 8
I as owner of the property or my employees with BUILDING ADDRESS
wages as their sole compensation will do the work and e o o ((9
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code) MOVING w TEL
I as owner of the property am exclusively contracting CONTRACTOR NO r o 5, a Q,.'8 8
with licensed contractors to construct the project (Sec ADDRESS \� �- "�� A\
tion 7044 Business and Professions Code)
CK FRMT-'
CONSTRUCTION LENDING AGENCY SETBACK YARD HWY TOTAPROPALINE WIDTH
I hereby affirm that there is a construction lending agency for i FRONT ,
the performance of the work for which this permit is issued P L +�
(Sec 3097 Civ C ) SIDE ,` r,I-,
Lender s Name y -
LD
MA Ref #� titer S
^�
Lender s Address P C Fee E Permit Fee -'
I certify that I have read this application and state that the Issuance Fee LDMA P/C,#
9 above information is correct I agree to comply with all County Investigation Fee
S ordinances and State laws relating to building construction Total Fee IDMA Perm #
and hereby authorize representatives of this'County to enter
m upon a obo a mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
1gnature of Applicant or Agent Date