HomeMy Public PortalAbout10018 LA ROSA DR_Building_12/12/1983_reroof WORKERS'COMPENSATION DECLARATION ). _ / i _� ,• ;
hereby affirm that f for Workers'
Cicote of consent to self APPLICAT.ION'- .FOR- WILDING PERMIT -
insure, or a certificate of Workers' Compensation Insurance, t I � • "- '
or a certified copy thereof(Sec. 3800, Lab. C.)
�t ��""{{�����]] ' /� •.. COUNTY OF LOS.ANGELES.- BUILDING AND.SAFETY
Policy No.�Company k
Certified copy is hereby furnished. IF BUILDING
. FOR APPLICANT TO FILL IN ADDRESS O" L ' O r� -
Certified copy is filed with the county building inspec- BUILDING n.1. /-
tion department. `ADDRESS - n- SA - LOCALITY J Z
) - ) - NEAREST
Dote /a— 4_3 Applicant CITY - ]` ZIP CROSS ST. Q• W f/l�1
CERTIFICATE OF:EXEMPTION.FR WORKERS' Viz' NO. OF BLDGS. 'ASSESSOR
COMPENSATION INSURANCE _ S+ZE OF LOT - .NOW ON LOT MAP BOOK I PAGE PARCEL
(This section need not be'completed if the permit is for one �n•L�Z. - - j^ US NE
hundred dollars ($100) or less ) TRACT V BLOCK L T NO. � NO. 1 0
- "TEL: `1\ ' /. SPECIAL y
I'certify that in the performance of.the work for which this OWNER S�• NO.' Y ' CONDITIONS
permit is issued!I shall not employ any person in any manner - - -. - DISTRICT .GROUP TYPE FIRE PROCESSED BY l
ADDRESS ' - Q O� _ CONST. ZONE
so as to become subject to the Workers'6ompensotion Laws. - _
C -- S o e 3 4�LT
Date - Applicant CITU- ZIP STATISTICAL CLASSIFICATION - APT CON O
NOTICE TO APPLICANT: If, after makingthis Certificate bf ARCHITECT OR. - TEL. qq ''
ENGINEER NO. CLASS NO. nWELL. UNITS_
Exemption, you should become subject to the Workers' C
Compensation provisions of the Labor.Code, you must forth- ADDRESS •' - - - - - SEWER MAPN
with comply with such provisions or,,this permit shall be' TEL
deemed revoked. '- - - VALIDATION
.CONTRACTOR' NO.�. b BK. PG,
. LICENSED CONTRACTORS DECLARATION LIC. _
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 5 V- VALUATION- -
(commencing with Section 7000)of Division 3 of the Business and- LIC
Professions Code, and my license is is full force and effect. CITY' NC�o U / 'CLASS l_ �� /j C2 60, OQ
1. p -D '/ SQ. F. NO.OF - NO. OF CHECK
License NAADD
d J _-T7r LicrClass—. .� SIZE STORIES FAMILIES ONE.� GP ).L-7 DESCRIPTION OF WORKNEW $ContractoDate I am exempt under Sec El -
ALTER FINAL '$7 :9.7.5 2•.5 R
B.BP.C. for this reason C7 d -✓ REPAIR DATE Q - .#. e e s e
USE OF B � 2 7 fi 0 p
Date ESE OFGBLDG. - - - DEMOL ❑ o o _ -
—FINAL
APPLICANT TEL - y
Signature PRINT ' NO. - • e'e-7'& O 06
OWNER-BUILDER DECLARATION _ - - - ' T/• _ +• d -
I hereby affirm that I am exempt from the Contractor's License - , 17 VC p ) a 1 2_a� -
Law for the following reason (Section 7031.5, Business and ADDRESS _ l 1 ? -.
Professions Code): PRE EN l'V Z
❑ - - BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will to the work and
' - the structure is not intended or offered for salefSection LOCALITY
7044, Businessand Professions Code). j MOVING TEL. -
1,.as owner of the property, am exclusively contracting d CONTRACTOR NO.
with licensed contractors to construct the project (Sec- i � - - -
- .'tion 7044, Business and Professions Code). ADDRESS - -
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE ' WIDTH ® -
(hereby affirm that there is a construction lending agency for t FRONT - - - - - - - • '
the performance of the work for which this permitis issued i P.I. - .{
(Sec 3097, Civ. C.). I SIDE
P.L.
Lender's Name
Lender's Address -
P.C. Fee$ Permit Fee - V' t
- '
certiffhat I have read this a licafian and state-that the -
siVonce Fee
above information is correct. I agree to building
with alLCoont 9
Y 9pp PY Y Investigation Fee _. I, - • - --_, _ - _
g. - ordinances and State laws relating to building'construction, \"- Total Fee -
u and hereby authorize representatives of this County'to anter - - '
upon the above-menfionedp ope ty for on purposes. - - - - - - - - '-'• - -
a �;/ nJ �f '/.•p� ,,,,- ;_ SEE REVERSE.FOR EXPLANATORY-LANGUAGE l _
Signature of Applicant or PAVt Dote- - r•.®s