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Home My Public Portal About10136 LA ROSA DR_Building__ WORKERS' COMPENSATION DECLARATION /w e -�,.�'^�FG�'(/wT/'� R � .T hereby affirm that have a certificate of consent to , or APPLICATION ■ V R G./ ILDING PERMIT Insure, or a certificate of Workers'Com penstion Insurance, or �/ a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company p 0 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Q J - Certified copy is filed with the county building inspec- gUILDtNG n �` ,('� :1 a 19, tion department. ADDRESS '/�1 )G G.n T� VTV� �l it LOCALITY NEARE Date Applicant CITY EIL L E (,. i r ZIP 7p (� CROSS ST. r • CERTIFICATEEXEMPTION FROM WORKERS' SIZE OF LOT a''X soy NOW ON LOTS MAP BOOK J PAGE � PARCELASSESSOR O(.J COMPENSATION INSURANCE � _ (This section need not be completed if the permit is for one tt11 (x USE ZONE MAP TRACT I V (, BLOCK LOTrIJO. , E- NE NO. hundred dollars ($100)or less) Pi 1 y n TEL (� n '` �d SPECIAL t y OWNER RM NO. G C CONDITION$ certify that in the performance of the work for which this' V permit is issued, shall not employ any person in any manner ��r�ss{{ cc Zs DISTRICT GROVP TYPE _FIRE PROCESSED BY ADDRESS 'V 1 G.T C A CONST. ZONE so as to become subject the Workers'Compensation Laws. - c •� CITY71-Ml ZIPQ1 7 O S'o !� Q Dale Applicant ARCHITECT OR TEL., STATISTICAL CLASSIFICATION APT . CONDO- V _ NOTICE TO APPLICANT: If, coo making this Certificate of ENGINEER NO. CLASS NO. DWELL. UNITS d Exemption, you should become subject to the Workers' y Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP Z with comply with such provisions or this permit shall be deemed revoked. , BK.TEL' G PG, VALIDATION CONTRACTOR VIJ NO. ' LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NQ. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC Professions Code, and my license is in full farce and effect. CITY CLASS 5 �� Q SQ. FT./1+ NO.OF NO. OF CHECK License Number Lic Class SIZE p+ 0 STORIES / FAMILIES ONE , ❑ g Contractor Date DESCRIPTION OF WORK NEW OADD I am exempt from the licensing requirements as I am a U(/O 'J"i ill SL licensed architect or a registered professional engineer ALTER FINAL ®— �( acting in my professional capacity (Section 7051, REPAIR Li DATE Business and Professions Code). USE OFFINAL DEMOL EXISTING BLDG. By - Lic.or Reg.No. Date - APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License - r Law for the following reason (Section 7031.5, Business and ADDRESS 2&Q 3 A Pensions Code): , PRESENT BUILDING 1, as owner of the, property, or my'employees with ADDRESS # e e s e 's wages as their sole compensation, will do the work and the structure is not intended or offered for sale(Section LOCALITY 2 e 1 3 3 0 0 7044, Business and Professions Code). MOVING TEL. - I, as owner of the property, am exclusively contracting CONTRACTOR NO. 3 0 0 d with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code).- 'I O,2 7-80 CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM EXIST, SET BACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT ..2 r the performance of the work for which this permit is issued P.I. Q Q o (Sec. 3097, Civ. C.). .SIDE P,I. Lender's Name Lender's Address P.C. Fee S Permit Fee " jw 1 certify that I have read this application and state that the Issuance Fee aabove information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee m and hereby authorize representatives of this County to enter i ( ona above-mentio d property for inspection ppurposees. - \/ IO`(j7•/f L/ SEE REVERSE FOR EXPLANATORY LANGUAGE IT I nature of Applicant or Agent Dote �s WORKERS'COMPENSATION DECLARATION suo4 hereby affirm that have a certificate of consent to self APPLICATION FOR BUILDING PERMIT ' insure, or aertificatP of Workers'Compenstion Insurance, or o certified copy thereof (Sec. 3800, Lob. C.) ' .. COUNTYOF LOS ANGELES '. BUILDING AND SAFETY Policy No. ' Company Certified copy hereby furnished. FOR APPLICANT TO FILL IN BUILDING El ADDRESS ❑ Certified'copy is filed with the county building inspec- BUILDING lion department. L ADDRESS O LOCALITY NEAREST Date 'Applicant CITY ZIP Q. CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP TRACT BLOCK LOT NO. NO. 0 hundred dollars ($100)or less.) i Y TEL. � SPECIAL d I certify that in the performance of the work for which this OWNER NO. `Z Z CONDITIONS Q permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCE ED By V so as to become subject to the Workers'Compensation Laws. ADDRESS CONST. ZONE a. Dote 6S. Applicant CITY ZIP `" STATISTICAL CLASSIFICATION APT. CONDO. V NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL, 9 W Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL UNITS_ N Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP Z with comply with such provisions or this permit shall be deemed revoked. CONTRACTOR TEL. �/ VALIDATION NO. BK. PG,�/ LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC Professions Code, and my license is in full force and effect. CITY CLASS $ 000 SO. FT. NO. OF NO. OF CHECK ' License Number Lic.Class SIZE 30o STORIES IFAMILIES ONE t 8 Contractor Date DESCRIPTION OF WORK NEW ❑ ❑ DD am exempt from the licensing professional as am a p licensed architect or a registered professional engineer ALTER ❑ FINAL �j ^L 8 O acting in my professional capacity (Section 7051, REPAIRDATE L O I Business and Professions Code). USE OF ❑ FINAL EXISTING BLDG. DEMOL ❑ By I!j , 'J ' Lic.or Reg.No. Date APPLICANT TEL. (l OWNER-BUILDER DECLARATION (PRINT) NO. . I hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT ❑ property, ED MING .or my emPtyeeswith / r ADDRESS wages as their sole compensation,will do the work and °Q 5 2 8 A the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code), MOVING TEL. 0 I, as owner of the property, am exclusively contracting CONTRACTOR NO. # o o e e e 1 with licensed contractors toconstructthe project (Sec- ADDRESS - 1 4200 tion 7044, Business and Professions Code). - J REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWV PROP. LINE WIDTH e e 1 42.0 0 5 ` I hereby affirm that there is a construclion lending agency for FRONT �U U 0 c, the performance of the work for which this permit is issued P.I, _-- 1 O 3;_8 2 (Sec. 3097, Civ. C.). - SIDE `^`4 P.I. Lender's Name ] '�7\j ` - Lender's Address P.C. Fee$ Permit Fee G7 V.J 0 w I certify that I have read this application and state that the Issuance Fee do, 4-0 a• above information is correct. I agree to comply with all CountyInvestigation Fee g ordinances and Stole laws relating to building construction, rami Fee ..Z..Z and hereby authorize representatives of this County to enter mup the above-me boned ape ty for inspection purposes. X23 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applico nt or gem Dote �6 .I