HomeMy Public PortalAbout6033ALESSANDRO AVE_Building (6) WORKERS' COMPENSATION DECLARATION
Fiet.by affirm that I 'have a certificate of consent to self A P P L I CATION FOR BUILDING PERMIT
insure^or a certificate of Workers' Compensation Insurance,
or a,,ert:fiod "copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- ADDRESSBUILDING
'
tion department. �
CITY L ZIP q ( U LOCALITY
Dare Applicant '7 N . OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT WON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT IPLOCK I LOT NO, MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) _ r!
OWNER '�j r . T �r7 7 1 USE ZONE MAP NO.
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESLI _ / CONDITIONS O
so as to become subject to the Workers' Compensation Laws.
CITY ZIP r1 7 Is 0 U
Date [J Applicant / ARCHITECT OR TEL. 0
PP DISTRICT GROUP TYPE FIRE 'PRO SSED BY
NOTICE TO APPLICANT: If, afte making this Certificate of ENGINEER NO. CONST. ZO� ~
Exemption, you should beco subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS i N
with comply with such provisions or this permit shall beTEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. —
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 2:2 DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO, SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
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
Contractor Date DESCRIPTION OF WOK y NEW ❑ $ rv_1�L
z ADD ❑
❑ 1.l'-u N-lir.l t I am exempt under Sec. � Poo.ALTER ❑
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
APPLICANT TEL.
Signature PRINT) FINAL / C'
h NER-BUILDER DECLARATION ( RINT NO.,
O. DATE
I hereby affirm at I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL -0-
Professions Code): PRESENT By �kp
I, as owner of the property, or my employees with BUILDING }
ADDRESS
wages as their sole compensation,will do the work and LOCALITY pop structure is not intended or offered for sale(Section
7044, Business and Professions Code.) MOVING TEL. �]��.•�'1
❑ 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 EXIST
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
U V O LDMA Ref. #
P.C. Fee $ Permit Fee
Lender's Address ,
o I certify that I have read this application and state that the Issuance Fee LDMA P/C#
0
S above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon t ave-menti n property for inspection purp#es.
0 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date