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HomeMy Public PortalAbout10310 LA ROSA DR_Building__ WORKERS' COMPENSATION D[CLARATION hereby affirm that 1 have certificate of consent to self APPLICATION FOR BUILDING PERMIT JI�I insure, ora certificate of Workers'Compensation Insurance, or a certified copy thereof (Sec. 3800, La .�.,. ' _ ',�: COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No3 Y;7 7 Company BUILDING El—certified copy is hereby furnished. a• ' - FOR APPLICANT TO'FILL IN ADDRESS b � � /v ElCertified copy is filed with the county building inspec- BUILDING tion department. 'ADDRESS `' LOCALITY Dote r/ J., G=S Applicant leJf /� - NEAREST �. ' CITY �'• ZIP CROSS 51. CERTIFICATE OF EXEMPTION FROM WO SIZE OF LOT �'r�. ' NOW FB LOTS. - \ MAP BOOK PAGE PARCEL COMPENSATION INSURANCE 7 (This section need not be completed if the permit is for oner USE ZONE MAP --{{ hundred dollars ($100)or less.) TRACT b (9 BLOCK I LOT NO. NO. O� TEL. / SPECIAL } I certify that in the performance of the work for which this OWNER NO. CONDITIONS 11 DISTRICT .GROUP TYPE FIRE PROCESSED BY O permit is issued, I shall not employ any person in any manner - - CONST ZONE V so as to become subject to the Workers'Compensation Laws. ADDRESS �/G'5 pp �� CTv - -�e` `ZIP "%Ae S�'� e-3 (� 3 rc W Date—Applicant .........CAL CLASSIFICATION APT. CONDO. h ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this Certificate of V ENGINEER NO. CLASS NO. Exemption, you should become subject to the Workers' DWELL. UNITS_ Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this .permit shall be / _ Z deemed revoked. - CONTR�f�G TELL s BK. PG, VALIDATION C6/'�/'y NO. Y5 1='�Q LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N S VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC y� Professions Code, and my license is in full force and effect. CITY CLASS b I $ SO.$� NO.OF NO.OF CHECK , License Number ���°r't- Lic Class Slyf%�� STORIES "� FAMILIES ONE , ® DESCRIPTION O NEW $ At a con,roct ��^�Sote O RG',!SA aE�. 9 APPR VR 3 I am execP t undo S ADD / Fit`lrz=°LiiilCslbiG i2PA4?OVe3'.la��"> ° FINA B.BP.C. for this reason _ ALTER ❑ DATE REPAIR ❑ USE OFF Date: DEMOL IAL EXISTING BLDG. By' V` Signature APP(LPCAN TEL OWNER-BUILDER DECLARATION RI L-d Al NO. Gf I hereby affirm that 1 am exempt from the Contractor's License ► / / _-2 8 3 3 A Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT ff e o e o 23 BUILDING I, as owner of the property, or my employees with ADDRESS 2 o - 57,37 wages as their sole compensation,will do the work and �`" \ the structure is not intended or offered for sale(Section LOCALITY o e e 57.37' 7044, Business and Professions Code). MOVING TEL. /� )/„- 6 6 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. <2 8 3.4 A CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH , I hereby affirm that there is a construction lending agency for FROM .. o 0 o e the performance of the work for which this permit is issued P.I. (Sec. 3097, Civ. C.). SIDE 2 6.60.75 P.1. m Lender's Name s qq � / n: � s � - 660756 Lender's Address P.C. Fee$ - 3J Permit Fee 4a S• 06 5,-83 I certify that I have read this application and state that the 5232 3 Issuance Fee have information is correct. I agree to comply with all County Investigation Fee / / 7 ordinances and State laws relating to building construction, Total Fee (! 4' 0 1 (J D and hereby authorize representatives of this County to enter upon the bove-mentioned pr perty for 'nspection purposes. - - e SEE REVERSE FOR EXPLANATORY LANGUAGE Signa of A7 ant Agent Dote ®r