HomeMy Public PortalAbout6033ALESSANDRO AVE_Building (5) WCRKERS COMPENSATION DECLARATION
y affirm that I hoe a certificate of consent to self APPLICATION FGRBUILDING PERMIT
i�'e or P cartiticafe of Workers Compensation Insurance
cifed copy thereof (Sec 3800 La4 b 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 [ADDRESS
ING
tion department r ESS
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Date Applicant .[_. t ZIP Y LOCALITY Qr(JO
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE F LOT NOW ON LOT ( CROSS ST "
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less ) BLOCK LOT NO MAP BOOK PAGE PARCEL
TEL USE
Z NE MAP
ER
I certify that in the performance of the work for which this NO NO
permit is issued I shall not employ any person in any manner SPECIAL
so as to become subject to the Workers Co ensation Laws - ' CONDITIONS O
Date' -2 Applicant CITY ZIP
NOTICE TO APPLICANT If after making ARCHITECT OR TEL s Certificate of DISTRICT GR UP TYPE FIRE PROCESSED BY O
Exemption you should become subject to the Workers ENGINEER NO _ CONST ZONE U
Compensation provisions of the Labor Code you must forth ADDRESS
with comply with such provisions or this permit shall be TELp•
deemed revoked CONTRACTOR /�l.�/ STATISTICAL CLASSII CA ION APT �NDO U)NO0�1` Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS
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I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS QO 1-0 r944,,44 04 tN0
(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 &4 VALIDATION
I p SQ FT NO OF NO OF CHECK BK PG
License Number 4�,33 Lic Class, 9- SIZE STORIES FAMILIES ONE
VALUATION
ADD
ContractorCMS) i-►cGazZ. `r Dote Z7�8C� DESCRIPTION OF WORK NEW- ❑
ADD ❑ $ 2
❑ I am exempt under Sec Old (X. CIDL. )01= ❑
ALTER
B 8P C for this reason REPAIR ❑ s
Date USE OF yy�� e. �,, DEMOL ❑
EXISTING BLDG Y�(I�f�/1 J Qr
Signature APPLICANT TELFINAS` 9 7 1 3 A
OWNER BUILDER DECLARATION PRINT IL. NO A4 NO f
DATR t
I hereby affirm that I am exempt from the Contractor s License fi 1
Law for the following reason (Section 7031 5 Business and ADDRESS �
b UJ ( FINA►', `I {� # o o a o o
Professions Code) By - • • 4 9 8 8
❑ BUILDING e • 0 4 9 8 8 v
I as owner of the property or my employees with ADDRESS
wages their sole compensation will o the work and � Z - 52,7-8 8
the structure
for is not intended or offered for sale(Section LOCALITY yr� ,� '
7044 Business and Professions Code) MOVING ,STEL ---- u_
❑ I as owner of the property am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec "r K, 4�
tion 7044 Business and Professions Code) ADDRESS
REQUIREDTOTAL SETBA
CONSTRUCTION LENDING AGENCY SET BACK yYARD 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
LDMA Ref N
Lender s Address
PC Fee$ Permit Fee
I certify that I have read this application and state that the Issuance Fee LDMA P/C M
o above information is correct I agree to comply with all County Investigation fee
0 ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter Total Fee LDMA Perm q
upon the above mentioned property for inspection purposes 1`
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Signature cUpplicant or Agent Date e e r
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