HomeMy Public PortalAbout6056ALESSANDRO AVE_Building WORKERS' COMPENSATION DECLARATION
hereby 00m than I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
1:1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS iv
9 Certified copy is filed with the county building inspec- BUILDING Al,Y tion department. ADDRESS � 0S6 IdL/63'.d�✓OR� A
Date H Appliconl� � CITY JOL ZIP !F/790 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST 7
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR
hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL
TEL. USE ONE MAP
I certify that in the performance of the work for which this OWNER / L� ,� NO*
permit is issued, I shall not employ any person in any manner ADDRESS i7 /� p/ , gyp SPECIAL ,
so as to become subject to the Workers'Compensation Laws. LW CONDITIONS O
Date Applicant CITY -� ZIP
U
ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT G OUP TYPE FIRE P ESSED BY O
Exemption, you should become subject to the Workers' ENGINEER NO. CON,ST./ ZO U
Compensation provisions of the Labor Code, you must forth- ADDRESS L/ , � V W
with comply with such provisions or this permit shall be p:
deemed revoked. ✓jlD3C/L— �NSZj TEL. STATISTICAL CLASSIFICATION APT. CONDO. N
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION W/ �.�rp �� LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS C NO.y2.3yf 9
(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 BK PGVALIDATION
SQ. FT. NO.OF NO. OF CHECK
License Number `*2>y9 S Lic.Class SIZE STORIES FAMILIES ONE
- .-X�!/.�fJ/6/� eitleT� NEW ❑ VALUATION
Contractor Fate // /� DESCRIPTION OF WORK 0-� 7
� ADD ❑ $ 7S
❑ I am exempt under Sec. �Pi�Q / ` ❑ 08364A.
ALTER
B.&P.C. for this reason REPAIR ❑ $ # 0 0 0 0 0,1
Date: USE OF EXISTING BLDG. �.�/jJ,rr/t/G� DEMOL ❑ 0 o 4 Q 5 0
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION. PRINT OJR&Cf ��O�ti NO.Z$�7.f� DATE o o o 4 Q 5 0 2
I hereby affirm that I am exempt from the Contractor's License ' �� / G r
Law for the following reason (Section 7031.5, Business and ADDRESS dI p// �/G/i✓ �._ FI L
--87
Professions Code): PRESENT
s 11, 1 6
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED YARD HWY TOTAL SETBACK FR
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE. JWIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
P.C. Fee$ Permit Fee �0� #
Lender's Address //, (I certify that I have read this application and state that the Issuance Fee V e J #above information is correct. I agree to comply with all County Investigation Feeordinances and State laws relating to building construction, Total Fee 1 ,� m. #
R and hereby authorize representatives of this County to enter
M
upon the above-mentioned propert for ' ection pu poses
/�G SEE REVERSE FOR EXPLANATORY LANGUAGE
n oture of Applicant or Agent Da