HomeMy Public PortalAbout6033ALESSANDRO AVE_Building (4) 1 O"r
WORKERS' COMPENSATION DECLARATION
1 gu*ro ebaffirm That i havecertificate of consent to Self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers'
br'
kers' Compensation Insur ;.e, •. �p,, r.
or a certified copy thereof (Sec. 3800, Lab. C.) 1 COUNTY OF LOS .*.,N'.t rS ,wr BUILDING AND SAFETY
Policy No. Company -
° BUILDING �L
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ' ADDRESS ° 733
r
❑ Certified copy is filed with the county building inspec- BUILDING ] ` 1 q� raw l �/��I .—r p
tion department. ADDRESS t'�!;i� �) >�o�,c J r-v ,6 Q
Date Applicant CITY � d°/�" /J ! �"r ZIP ���✓ LOCALITY r t°
NO. OF BLDGS: NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE SSESSOR -
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. 14,AP BOOK PAGE PARCEL
hundred dollars ($100) or less.) p TEL.
OWNER �?{�����)'`�/+ ?l"F:r` `,°iZr�k NO.._�(;I:J`(�J USE ZONE MAP
NO.
I certify that in the performance of the work for which this �' D_ SPECIAL >_
permit is issued, I shall not employ any person in any manner ADDRESS " / CONDITIONS 0-
so
so as to become subject to the Workers' Compensation.Laws. O
CITY ZIP
Date Applicant ARCHITECT OR/, TEL. tY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER /;„I I'll NO DISTRICT GROUP TCYOPE MORE PR D BY O
Exemption, you should become subject to the Workers' V
Compensation provisions of the Labor Code, you must forth- ADDRESS J�60ir a
with comply with such provisions or This permit shall be TEL. STATISTICAL CLASSIFICATION APT. CO O, N
deemed revoked. CONTRACTOR L�/ Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm That I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP
and Professions Code,and my license is in full force and.effect.. CITY CLASS BK PG VALIDATION
SQ. FT NO. OF NO. OF CHECK
License Number Lic. .Class SIZE STORIES FAMILIES ONE
VALUATION
(20
Contractor Date DESCRIPTION OF WORK NEW El ,$
ADD , pop❑I am exempt under Sec. ALTER ❑
B.&P.C. for this reason REPAIR ❑ $
Date: ' USE OF
i EXISTING BLDG. DEMOL ❑
APPL16ANT TEL
Signature + + FINAL
OWNER-BUILDER DECLARATION (PRINT)' NO
� . DATE -
I hereby affirm That I am exempt from the Contractor's License t
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL -T.
n
BDING
Pr fessions Code): PRESENT By
�`. I, as owner of the property, or my employees with ADDRESS !4
wages as Their sole compensation,will do the work and LOCALITY
the structure is not intended or offered for sale(Section
7044, Business and Professions Code.) MOVING TEL. Ff_ s oY
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:) ICi
REQUIRED TOTAL SETBACK FROM EXIST.'-
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH". €i s ( � '�'
. 24
1 hereby affirm that There is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L. {;-=`I. "
(Sec. 3097, Civ. C.). SIDE- --HE-_K
Lender's Name CH
9 7P.C. Fee$ V'�d' Permit Fee �,rj LDMA Ref. it
Lender':,Address - - rs r /-�-,
li 1_I qq
1 . 7I 11r t.
a •,certify that I have read this application and state that the Issuance Fee LD"
P/C#
c,•
."above information is correct. I agree to comply with all County Investigation Fee t + ij'] 21:'_,
6 ordinances and State laws relating To building construction, Total Fee c LDMA Perm. #
a and hereby authorize representatives of This County to enter
upon the above-menti ned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of.Applicant or Agent Date'