HomeMy Public PortalAbout6042ALESSANDRO AVE_Building WORKERS COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to Self APPLICATION F O R- BUILDING , P E RM I T
' insure or a certificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lob C )
COUNTY OF LOS ANGELES � . BUILDING AND SAFETY
Policy No Company
El Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS G�
Certified copy is filed with the county building inspec BUILDING "
tion department ADDRESS 7 _ LOCALITY i/ GL
d NEAREST /_4A/ se
Date Applicant CITY ` ZIP CROSS ST C.ltf"r/� !`7
CERTIFICATE OF EXEMPTION FROM WORKERS O OF BLDGS ASSESSORc7 +
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK �J� c7 PAGE d-:5
PARCE
(This section need not be completed if the permit is for oneUSE ZONE MAP
00 Z
hundred dollars ($100)or less ) TRACT BLOCK LOT NO NO
SPECIAL �
I certify that in the performance of the work for which this 6WN t CONDITIONS IL
DISTRICTGROUP TYPE FIRE PROLE D BY O
permit is issued I shall not employ any person in any manner CONST ZONE V
so as to become subject to the Wor Com nsa n L s ADDRESS
.� dr~ - �
Dat Applica CITY G ZIP STATISTICAL CLASSIFICATION APT CONDO r (—
ARCHITECT OR TEL
NOTICE TO APPLICANT If after makin tis Certificate of ENGINEER CLASS NO DWELL UNITS_ W
Exemption you should become subject to the Worke4A
Compensation provisions of the Labor Code you must for ADDRESS SEWER MAP
with comply with such provisions or this permit shall be TEL /s I '
deemed revoked CONTRACTOR NO BK PG ( / VALIDATION
T
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALLI ON
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code and my license is in,full force and effect CI CLASS $ bOt7
SQ FTZl� NO OF NO OF CHECK
License Number Lic Class SIZE STORIES FAMILIES ONE
Contractor Date DESCRIPTION OF WORK
d NEW $ r
� ADD
I am exempt under Sec
ALTER FINAL �/O
v
REP l�
B 8P C for this reason R DATE
USE OF FINAL
Date EXISTING BLDG -. DEMOL By wfiCJ
Signature APPLICANT TEL41
OWNER BUILDER DECLARATION sm&--1/22
I hereby affirm that I am exempt from the Contractor s License , a
Law for the following reason (Section 7031 5 Business and ADDRESS S
Professions Code) PEEN
BUILDING
I as owner of the property or my employees with ADDRESS ' '--91069A '
wages as their sole compensation will do the work andj
the structure is not intended or offered for sale(Section LOCALITY _
o
7044 Business and Professions Code) MOVING o 0 o'.
I as owner of the property am exclusively contracting CONTRACTOR NO _ 2'- e 4 9 8 8
with licensed contractors to construct the project (Sec ( ,
ADDRESS a a o 4 9 8 8 2
tion 7044 Business and Professions Code) -,
REQUIRED TOTAL SETBACK FROM EXIST � 20:CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINF WIDTH , '
I hereby affirm that there is a construction lending agency for FRONT — , - 0 5 0 8'—8 4
the performance of the work for which this permit is issued P L +~
(Sec 3097 Civ C ) SIDE
m PL
Lender s Name
PC Fee$ T Permit Fee y
Lender s Address
I certify that I have read this application and state that the a Issuance Fee 6
above information is correct I agree to comply with all County Investigation Fee ✓f/ f
ordinances and State laws relating to building construction Total Fee / a
sty and hereby authorize representatives of this Countyrto enter
upon above mens d pro erty for spection purposes
o _ SEE REVERSE FOR EXPLY
ANATORLANGUAGE
� Signature pplicant or Agent Data