HomeMy Public PortalAbout10320 LA ROSA DR_Building__ WORKERS'COMPENSATION DECLARATION C..
hereby affirm that /. I
havecertificate of consent to =elf APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, L b. C.) ,f
Policyt�.lCompany -P. L,._e' COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING
Certified copy is hereby furnished. ^`^y t '%=} FOR APPLICANT TO FILL IN ADDRESS Ad-a '
Certified copy is filed with the county building inspec- BUIDOING
• .3r�O J
tion department. / ADDRESS 0 l�Z O i LOCALITY
4+ ��0la�,!5 CITY NEAREST
Date �i Applicant - .ZIP CROSS ST. �.
CERTIFICATE OF EXEMPTION FRO WORKERS' NO. OF BLDGS. ASSESSOR
COMPENSATION INSUR NCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one / x USE ZONE MAP 2
hundred dollars ($100)or less.) TR��9 BLOCK LOT NO. �� NO. 1:2 • Q
TEL // SPECIAL y
NO
certify that in the performance of the work for which this OWNE . CONDITIONS d
67
permit is issued, I shall not employ any person in any manner - DISTRICT .GROUP TYPE FIRE PRO ESSED BY O
so as to become subject to the Workers'Compensation Laws. ADDRESS / D CONST. ZONE V
Date Applicant CITY ZIP /®®� STATISTICAL CLASSIFICATION APT. CONDO. _ O
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. W
ENGINEER NO. CLASS NO. 19 UNITS_
Exemption, you should become subject to the Workers S
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. CONT ,Pe`'z /�G/yJk, ��8o BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS t� VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC ,'7'J��
Professions Code, and my license is in full force and effect. CITY CLASS Z $ 5 "� — ,
�5 - SO. FT- NO.OF NO. OF CHECK
License Number T Z;Vll6 Lia.Class SIZ 6l,/1 STORIES FAMILIES ONE �• O d C)
G �5 DESCRIPTION OF WQ
Contract to NEW
ADD ❑ L 'fi[i!t')i: F'S: i :T ftnt,T`t�:B
I am exenfpl ncl6r S c ALTER ❑ FINAL _z7_ 9� l'f�)1 �i+Q�:,) L:pi•4L SS�[);�rx�j �
B.&P.C. for this reasonDATE O
REPAIR ❑ s`:;iAL B.iQCI?r°G QItPIVf'r9f/`c.n,1!/��'/'
Date'. DEMOL USEOF ' ❑ FINAL
EXISTING BLDG. RY .a'�j- �V
'Signature APPLICA TEL
OWNER-BUILDER DECLARATION PR /C i✓ NG.yy��88a3 �/ ;9-2831 A
_ I hereby affirm that I am exempt from the Contractors License Poo Pe. fj o ° 0 0 2�j
Low for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): PRESENT
OBUILDING '�,3 .2 ° ° 87.318
I, as owner of the property, or my employees with ADDRESS 7
wages as their sole compensation,will do the work and /J G `7 8 73 8 5
the structure is not intended or offered for.sale(Section LOCALITY 'T 7
7044, Business and Professions Code), MOVING TEL. 06 1 5-8 3
I, as owner of the property, am exclusively contracting CONTRACTOR NO. / !/
with licensed contractors to construct the project (Sec- ADDRESS (9 A
'tion 7044, Business and Professions Code). r
REQUIRED TOTAL SETBACK FROM EXIST. z 2 8 3 2 A
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT . polo. ° o o s o 1
ihe performance of the work for which this permit is issued P.L. '
Sec. 3097, Civ. C.). SIDE. 2 - 593-2 5
P.L.
m Lender's Name �j�J p -° ° 5 9 3 2 5 6
Lender's Address P:C. fee$ J7 97 Permit Fee Seo2.., ' �L� 0615-83
rc 1 certify that I hove read this application and state that the /, Issuance Fee /a-SD
above information is correct. I agree to comply with:all County Investigation Fee
g ordinances and State laws relating to building construction, Total Fee
a and hereby authorize representatives of this County to enter
upon.th above-me
�ntti ned,property for nspection purposes. -
u T ° SEE REVERSE FOR EXPLANATORY LANGUAGE ,
S�re o PlOifit or Agent/ Date Os