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HomeMy Public PortalAbout6056ALESSANDRO AVE_Building (2) WORKERS'COMPENSATION DECLARATION Ct a` �,f� nscrreboraafirm zertif carte off Workers' Compensatioa certificate of n e-int to Insuran of A P P L I CAT I O F U 1 L D I PERMIT or o certified copy thereof (Sec. 3800, Lab. C.) � �1q2 Company 33rrj%,tC� `i _� COUNTY OF LOS ANGELES 1� , BUILDING AND SAFETY Policy No.� isJ 1:1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS LOCALITY 12��S_,— licant • CROSSST.NEAREST Date A� ,\ �9pp l� ��n.t=' CIT ZIP CERTIFICATE OF EXEMPTION FROM WORKERS' j NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT SD 13 ` NOW ON LOT 4'X- MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one Por. La't— USE Z E MAP D hundred dollars ($100)or less.) TRACT _ BLOCK LOT NO. NO. �� TEL. 0< 1 SPECIAL } I certify that in the performance of the work for which this OWNER O. g CONDITIONS permit is issued, I shall not employ any person in any manner r DISTRICT I GROUP ITYPE FIRE PROCESSED BY O so as to become subject to the Workers'Compensation Laws. ADDRESS CONST ZONE �0� ©rz� a � = Date Applicant CITY ZIP ®ARCHITECT OR TEL. STATISTICAL CLASSIFICATION APT. CONDO. NOTICE TO APPLICANT: If, after'making this Certificate of ENGINEER NO. LU Exemption, you should become subject to the Workers' �`� CLASS NO.2 J_DWELL. UNITS CL Compensation provisions of the Labor Code, you must forth- Nf ADDRESS ` SEWER MAP with comply with such provisions or this permit shall be � deemed revoked. TEL'CONTRACTOR N \ BK PG VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS S: "Z . 3 VALUATION (commencing with Section 7000)of Division 3 of the Business and Professions Code, and my license is in full force and effect. CITY, a CLASS — $LIC. ` o� ► SQ. FJ� O. OF NO."OF CHECK License Number ''3gS4Sa Lic.Class Qc,_ SIZE`',(_ /1 STORIES ` FAMILIES ONE ContractorC�D\`g. ra S,�Date l'•Z,—V4-—tk DESCRIPTION OF WORK NEW $ b ADD I am exempt under Sec. v1ti ALTER (3 FINAL B.&P.C. for this reasonDATE REPAIR Date: USE OF EXISTING BLDG. DE FINAL �d Signature APPLICANT TEL. 14 By OWNER-BUILDER DECLARATION PRINT NO. — I hereby affirm that I am exempt from the Contractor's LicensePoo '_'7 6 a f A Law for the following reason (Section 7031.5, Business and ADDRESS 2 / i 2gu J6� Professions Code): PRE EN BU LDING I, as owner of the property, or my employees with ADIDRESS 2 0 2 9 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. ° - 29050r'; I, as owner of the property, am exclusively contracting CONTRACTOR NO. 12: 1 6 -83 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 F P.L. e Lender's Name $ P.C. Fee$ Permit Fee j� Q Lender's Address I certify that I have read this application and state that the Issuance Fee I D� above information is correct. I agree to comply with.all County Investigation Fee $ ordinances and State laws relating to building construction, Total Fee 2-- •r u and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . Signature of Applicant or Agent Date ®s