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HomeMy Public PortalAbout10300 LA ROSA DR_Building__ WORKERS'COMPENSATION DECLARATION Q hereby affirm that I haver certificate of conseff Ins rant I, APPLICATION FOR BUILDING PERMIT 11SI insure, or a certificate of Workers' Compensation Insurance, - or a certified copy thereof"(Sec. 3800, Lab. C:) COUNTY OF LOS ANGELES BUILDING AND SAFETY � } Polity Na Company BUILING r Certified copy Is hereby Furnished. FOR APPLICANT TO FILL IN - - ADDRESS �O �7 ✓ Certified copy is filed with the county building inspec- BUILDING n i tion department. ADDRESS A 9 R- LOCALITY a C.`T NEAREST Date Applicant CITY IT 1.. CI ZIP OLS CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' r O. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT ' NOW ON LOT MAP BOOK I PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP . hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. 11 TEL. r SPECIAL } I certify that in the performance of the work for which this OWNER p tl NO. CONDITIONS a permit is issued, I shall not employ any person in any manner _ DISTRICT .GROUP TYPE FIRE PROCESSED BY 0 ADDRESS CONST. ZONE so as to become subject to the Workers'Compensation Laws. lid 3 C'7O -�a 6 � ^ ate 91-i0_ Applicant J CITY ZIP 91 STATISTICALC SSIFICATION APT. CONDO. rQ - NOTICE TO APPLICANT: If, after making this 'Certificate Of ARCHITECT OR TEL. �� U UNITS_ w 'Exemption, you should become subject to the Workers' ENGINEER oR J NO. CLASS NO. DINNER asommi WELL. d Compensation provisions of the Labor Code, you must forth- ADDRESS - - SEWER MAP with comply with such provisions or this permit shall be deemed revoked. 2� TEL. BK. PG, VALIDATION CONTRACTOR u 9 NO. LICENSEDCONTRACTORSDECLARATION 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 $ SQ. FT. / NO.OF NO.OF CHECK 'license Number Li<.Class SIZE J STORIES FAMILIES ONE . . i I NEW f4 $ Contractor Date DESCRIPTION OF WORK .� ADD Li I am exempt under Sec. welix ALTER FINAL A / REPAIR .r Off/ B.BP.C. For this reason - � DATE Y / O r Date: EXISTTIING BLDG. - FA - DEMOL O Y AL Signature APPLICANT TEL. !— OWNER-BUILDER DECLARATION PRINT 9 p NO. I hereby affirm that I am exempt from the Contractor's License gDDRE55 �� 11 A L+ , - ' Law for the following reason (Section 7031'.5, Business and Pr fassions Code): RE ENT f O A I, as owner of the property, or my employees with BUILDINGADDRESS o e a a a 1 wages as their sole compensation,will do the work and , the structure is not intended or offered for sale(Section LOCALITY '2 o - 967.Jc 7044, Business and Professions Code). - MOVING TEL. ' I, as owner of the property, am exclusively contracting CONTRACTOR NO. -0.0 . 967_F with licensed contractors to construct the project (Sec- ADDRESS 'tion 7044, Business and Professions Code). 0213-84 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 P.L. m Lender's Name Lender's Address P.C. Fee$ Permit Fee C(� I certify that I have read this application and state that theIssuonce Fee p S� above information is correct. I agree to comply with.all County Investigation Fee r g ordinances and State laws relating to building construction, Total Fee J u and hereby authorize representatives of this County to enter i upon the above-mentioned property for inspection purposes. pZ^ /0 SEE REVERSE FOR EXPLANATORY LANGUAGE 14 Slgnature of Applicant or Ngent D.L. ®s � WORKERS' COMPENSATION DECLARATION T� hereby affirm fhavecertificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers'Compensation Insurance, or a certified copy thereof (Sec. 3800, COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. / 7� Company �G ©/Certified copy Is hereby furnished. FOR APPLICANT TO FILL IN - BUILDINGADDRESS e),.30 w Certified copy is filed with the county building inspec- BUILDING 1,r/�. /_ tion department. / ADDRESS ,/r+0/ G. /_p $ LOCALITY NEA Date �� ---, Applicant - >' _1 s CITY �� ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKER - NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT 7 f4*16' NOW ON LOT MAP BOOK I PAGE PARCEL (This section need not be completed if the permit is for one •� q USE ZONE MAP hundred dollars ($100)or less.) TRACT.3/ BLOCK LOT NO. / NO. TEL SPECIAL } I certify that in the performance of the work for which this OWNER - NO. '/ CONDITIONS It. permit is issued, I shall not employ any person in any manner i DISTRICT .GROUP TYPE FIRE PROC ED BV O so as to become subject ro the Workers'Compensation Laws. ADDRESS " �-fi �/��� / �� � CONST. �NE U /7� A' ZIP ��e� y Ir// O Date Applicant CITY STATISTICAL CLASSIFICATION APT. CONDO. H ARCHITECT OR TEL. ,.� NOTICE TO APPLICANT: If, coo making this Certificate of ENGINEER NO. CLASS NO.vt_ W - Exemption, you should become subject to the Workers' DWELL UNITS_ ' 6 Compensation provisions of the Labor Code, you must forth- to with comply with such provisions or this permit shall be 'ADDRESS SEWER MAP Z deemed revoked. CONTRAOTli /4t745;1A1*X99 BK-- PG, VALIDATION LICENSED CONTRACTORS DECLARATION !,r� I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO, GS�� VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. ��jj - Professions Code, and my license is in full force and effect. CITY LIC. O� �.�./ ' — SQ. FT NO.OF NO. Of CHECK License Number ¢'�-� / Lic Class 1 SIZE / STORIES FAMILIES ONE pL� 7 , Cont(a� Li4 ' Date el, ��� j DESCRIPTION OF WOR NEW 'OJ $ / fD a o I am ex mpt un er ec ADD ❑ 0RADI E PEtR MIT I Ei JLRE.O /,,� ALTER ❑ FINAL // r,DOdGH GRADING APPROVED�W94, B.&P.C.for this reasonDATE l REPAIR ❑ FINAL GRADING APPROVED: Date: USE OF ❑ - 1-"•'� • EXISTING BLDG. DEMOL FINAL Signature APPLICA TEL.t�// Y - OWNER-BUILDER DECLARATION PRI iG NO✓y_i I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS n j Professions Code): PRESENT �"3 aBUILDING I, as owner of the property, or my employees with ADDRESS L wages as their sole compensation,will do the work and yp -7, 4;� Q the structure is not intended or offered for sale(Section LOCALITY p r' — 7044, Business and Professions Code). MOVING TEL. ��1 L O-3 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 TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD HwY PROP. UNE WIDTH hereby affirm that there is o construction lending agency for FRONT ` !heperformanceof the work for which this permit is issued P.I. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name - P.C. Fee$ c 0 Permit Fee Lender's Address 9 I certify that I have read this application and state that the tr S ,2— Issuonce Fee /USS a above information is correct. I agree to comply with.all County Investigalion Fee g ordinances and State laws relating to building construction, Total Fee ✓(4 06 and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. , SEE REVERSE FOR EXPLANATORY LANGUAGE Signq a of Appjl ant A I Data .®s