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