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HomeMy Public PortalAbout10315 LA ROSA DR_Building__ WORKERS'COMPENSATION DECLARATION hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT ILIO insure, or a certificate of Workers' Compensation Insurance, ' ora certified copy thereof (Sec. 3800, Lab��Cy // COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy RTo./3 �/ Company "~"^-""'� Certified copy Is hereby furnished. FOR APPLICANT TO FILL IN nooae55 f". �!{_ Certified copy is filed with the county building ibspec- [ADDRESS G // tion department. S 0,3 �,G ps LOCAIITV NEAREST Date Applicant CITY .G : ZIP CROSS ST. ...J CERTIFICATE OF EXEMPTION FROM RK S' NO. OF BLDGS. ,p ASSESSOR COMPENSATION INSURA CE LOT / OO NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP (! hundred dollars ($100)or less.) O BLOCK LOT NO. Zi NO. �© TEL. / SPECIAL r I certify that in the performance.of the work for which this + NO. - CONDITIONS 1 permit is issued, I shall not employ any person in any manner /' _ DISTRICT .GROUP TYPE FIRE PRO SSED BY O so as to become subject to the Workers"Compensation Laws. / %�. CONST. ZONE V 09 Date ' Applicant ZIP ®�� STATISTICAL CLASSIFICATION APT. CONDO. 0 NOTICE TO APPLICANT: If, offer making this Certificate of ECT OR TEL sER NO. CLASS NO. DWELL. UNITS_ W Exemption; you should become subject to the Workers' IL Compensation provisions of the Labor Code, you must forth- .ADDRESS SEWER MAP N with comply with such provisions or this permit shall be Z deemed revoked. ` TEL' - - YgK, PG, VALIDATION CONTRA U /�4 �Y NO. LICENSED CONTRACTORS DECLARATION LIC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 4e 6- 6 VALUATION ' (commencing with Section 7000)of Division 3 of the Business and LIC 1 l�'+p� Professions Code, and m license is in.full force and effect. CITY CLASS S ✓ , G rL SO. FT. Z NO.OF ` NO. OF / CHECK t License Number 2V406 7 Lic Class SIZE �-�% STORIES / FAMILIES '♦�/ ONE �+ DESCRIPTION OF ry �� may/ NEW ® $ Contractor E'�t> Y'/�CC��/ ]ate � ��r'7 I am exempt under Sec. �.�: ADD ❑ - L%r�rs�?I;'PE3ftseT REQUIRED ALTER ❑ DATE E;uu : ±'a^[�D€'>G GPPF}DVED4/4f?,t BAP.C. for this reason REPAIR ❑ �.FilA�. Nit1Hu:1tii3 'fi PPta Dt7tD;d �i Date: USE t DEMOL - FINAL EXE Of BLDG. l�/ ❑ By Signature APP PCA /� N0' ^�2eQ.� OWNER-BUILDER DECLARATION [s 0' ,. 10e /���. I hereby affirm that I am exempt from the Contractors License Low for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT = 2 82 9 A ❑ BUILDING 7 �i 1, as owner of the property, or my employees with ADDRESS 7 7 ° e e e 2 j wages as their sole compensation,will do the work and J / the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. / y� Zn o e 8 7, J 8 I, as owner of the property, am exclusively contracting CONTRACTOR NO. y'1V`p n = with licensed contractorstoconstruct the project (Sec- r' ° ` ` 7.7 C v 'tion 7044, Business and Professions Code). ADDRESS REQUIRED TOTAL SETBACK FROM EXIST. P 6 1 5-83 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP, LINE WIDTH hereby affirm that there is a construction lending agency for FRONT , 2 fl-j 0 A the performance of the work for which this permit is issued P.IT (Set. 3097, Civ. C.). - SIDE ,r a ° o ° 0 1 P.1. m Lender's.Name _ 7 - ^/7 . — 9-325 $ P.C. Fee 5 .J Permit Fee �Q ', 7s- Lender's Address r Q I certify that I have read this application-and state that the � ' Issuance Fee U, above information is correct. I agree to comply with all County Investigation Fee D 1 5-815 g ordinances and State laws relating to building construction, Total Fee Sf� ats G and hereby authorize representatives of this County to enter Upon the above-mentioned ro rty foorr ifspection purposes. ��Sj-}� SEE REVERSE FOR EXPLANATORY LANGUAGE `n Sign re of Appy1'' an Agent Date �, ®s _ _ W