HomeMy Public PortalAbout10232 LA ROSA DR_Building__ . .
- -WORKERS'COMPENSATION,DECLARATIOCi - - -D. •, ' • - -
I hereby affirm that•I have..-certificate of consent to self t - `-A■ PLICATION - 'FOR -BUILDINGti PERMIT ��
11 Insure, ora certificate of Workers'Compenehon Insurance, orF, s -
a cernfled copy thereof (Sec. 3800, Lab. C.) 'COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoQ-W:(OR4 Company BUILDING-
- ar Certlfled`copy is hereby furnished.- - '- -FOR`APPLICANT TO.FILL IN: - 'P. T
I� ADDRESS
^IJ Cei-Wied'.cbpy Is filed'with the county bwldl ng;inspec BUILDING - \
IJ don de drt"rit + ADDRESS y - ��
p 1 ' n
Date 13, Applicront t CITY .� 'ZIP L .L��
- CROSS NEAREST ST. n/ 1N' -
°. CERTIFICATE OFEXEMPTIONFROM:WORKE + ` " ` NO. OFBLDGS.. - A. ASSESSOR -
COMPENSATION.INSURANCE'^� - SIZE OF LOT., - NOW ON LOT MAP BOOK, PAGE ! PARCEL
„(This'section need notbe completed if the permit is.forone - _ USE ZONE MAP
hundred dollars ($100),unless.) _ ,� TRACT Y BLOCK LOTNO NO. -
TEL. —n ,,, SPECIAL S
r OWNER G NO. // CONDITIONS
I�'�erttfy that In'the performance of the work for which this, _
DISTRICT GROUP TYPE FIRE P CESSED BY O
permit Is Issued; 1 shall nofemploy any person In any manner 4 � �-U
so as to become, ADDRESS .0L. CONST JE 1
subject to the Workers {ompensation Laws _ 'Im
Dote ' Applicant '- • t' CITY V ZIP / STATISTICAL CLASSIFICATION .. - APT. CONDO. V
•NOTICE TO APPLICANT W'6fter-rr;oking this Certificate of -� ARCMTECT.OR - 1 _. TEL. ry W
`Exempt ion's+you' should become subject to`,the Workers' ENGINEER .t '; ;NO.' CLASS NO. DWELL UNITS_ 6
Ca Pe
of the Labor Code, you mist"forth 'ADDRESS. SEWER MAP Z
'-with comply,with such provlslons� or:.this permit shall be _ i' y, ' 1 f '
deemed revoked sr COY 1 \ W NO. IJ� 1 I1 b VALIDATION -
LICENSEDCONTRACTORSDECLARATION
I hereby affirm that I am licensed'undeI provisions of Chapter 9 VI•. VALUATION• '
(commencing with Section 7000)of Division 3 of the Business and - h tt6 RR - dp
Professions Code, and'an license is in full force and effect.. - CITY' I .CLASS_N ^ 3 �Q L 2-5'1> -
•],� '�� _ +E17 I SQ. FT. NO,OF NO. OF -CHECK -
LicenseNu er JLic.'Classy."^; S1ZE STORIES ,ASF FAMILIES ONE -
'i �Ilt Ve, ,T DESCRIPTION.OF WORK. pmacR NEW - O S
Contracio - Date --
am,exempt from e licensing requirements as I am a /P bA ^>"•� R ' - 'ADD _ -
Ilcensec archltei ora registered professional'engineer p„�- ALTER. FINAL I'7C
acting, in mn professional capacity, (Section 7051 ,A - DATE GU•- -
Buslness'and Professions Code). U OF _ - /� �,.� REPAIR .'
r -
EXISTING BLDG �'�7D-C'� 'DEMOL''� BIN -t
Lic.or Reg No: Date >.� APPLICANT 1 r TEL. �I{ Y-
OWNER=BUILDER DECLARATION "• s '`i PRINT L " NO. 4
I hereby affirm that I am exempt from the Contractors License - '/` ��- �. - - - '�-5 9 9,'4 A
.� Low,for the,following reason.(Section,7031 5,.Business,and" .' ;
- Professions Code).. n PRE ENT . - - o s.•
- .. , - BUILDING.' <. .., #t• T .i. . -
'I, as owner'of•the property, or..,my;employees with ADDRESS
wages as their sale compensation,will do the work and - r 2 • 13 3.;L 5
the structure is'nohintended or offered for sale(Section LOCALITY - - - ,- -> - ' •— -
7044, Business and Professions Code) > d MOVING TEL - • •t 1 3'3 2'5 U
_ IZ as owner of the property, am excluswelycontracting CONTRACTOR= • ry - .NO,r
with I Icensedcontractors to construct the protect (Sec- -
tion.7044,-Besiness and Professions Code).- -- _.' ADDRESS -
' REQUIREDTOTAL SETBACK FROM' .'EXIST. — -
'CONSTRUCTION LENDING AGENCY. ) SETBACK YARD HWY PROP, LINE WIDTH
I hereby ofWari that there is a'construction lending agency for C FRONT
.the performance of the work for which this permit is issued P:'{. x . 1
(Sec 3097,.0v1.CI).. _ . . `. ' _ p. '.SIDE:. _ .. ..: .. .. - .. � •r_ ' \•. ,
., . .P.L. .- . - r `f.
_Lender s Name'
t P.C. Permit Fee-' _
Lenders Address _ - - X' to
?., I certify that htt
ove-read this a hcation and state that the t
y PP i Issuance'Fee -
a above Information Is correci-I:agree to comply with all County, vestigmion F e --. - - -
�oidinoaces a`nd.Stote laws reloting-to-building construction, Totdl Fee~' -
m and h re by authanze represenmtives of this Coumy_to.enter '
a -up`o bo e-mentioned propertyfor"inspection p poses
SEE REVERSE•FOR EXPLANATORY LANGUAGE
Signature ofp Ic. or Agent Dae