HomeMy Public PortalAbout10330 LA ROSA DR_Building__ WORKERS'COMPENSATION DECLARATION T, GI
hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or li yertifie��copy thereof (Sec. 3800, Lab, C,)� J ,
NNtif-1 .CLICt— .�}��Y !/ COUNTY OF LOS ANGELES B I DING AND SAFETY
Policy o. l Company Q BUILDING
2 2A
a-tertified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS �mC_
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS Q� jo Z�p'oe LOCALITY
NEAREST
Date Applicant CITY ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FRO O I NO. OF BLDGS. ASSESSOR
COMPENSATION INSU CE SIZE OF LOT Q NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP TRACT
hundred dollars ($100)or less.) TRACT �/ O BLOCK LOTTEL. NO. OC ()
. P / SPECIAL
I certify that in the performance of the work for which this OWNER NO. CONDITIONS d
permit is issued, I shall not employ any person in any mannerADDRE CONST.DISTRICT GROUP TYPE FIRE PRO ESSED BY O
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so as to become subject to the Workers'Compensation laws. � ,S;Or D 2 V U
3 ZONE
EIS
Dote Applicant CITY ��-�•GC�+� ZIP ARCHITECT OR TEL. STATISTICAL CLASSIFICATION APT. CONDO. O
NOTICE TO APPLICANT: If, after making this Certificate of _ U
Exemption, you Should become subject to the Workers' ENGINEER NO. CLASS NO.� DWELT. UNITS_ W�
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. - C �09 NO L/'7� BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC. p
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 CL4 $
�fS SO. FT NO.OF NO.OF CHECKpop
License Number�-6S c G {ia Class SIZ / STORIES FAMILIES N ONE 0 G, '1 ^`
E V
Contra Dole (•' S T ! - DESCRIPTIO
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ADD
I am ex pt and r ALTER E] FINAL j,� -:nhlS'L': P�.Fi",Mf MQUIRED
8.8P.C. for this reason - ❑ DATE +� r0 ¢' I]M" A GRADING AMUVeD��J��
REPAIR
Date: USE OF F :{I'ii1L (i FiADliiw QPp$`�{f ICU:/�
E%ISTING BLDG. DEMOL ❑ BYINAL 1///ey
Signature - APPLICA TEL -
OWNER-BUILDER DECLARATION PR it�/tr. NO'Y Z�q3
I hereby affirm that I am exempt from the Contractor's license , P L„,
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): PRE
BUILDING 2 8 3.9 A
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and �7 GQ 11
the structure is not intended or offered for sole(Section LOCALITY z
7044, Business and Professions Code), MOVING TEL. c 0 G`•-' 2 e o 6 3. 1 2
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS o o e 6 3 1 25
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH , 0b 1 5-83
I hereby affirm that there is o construction lending agency for FRONT p 2$�h O A
the performance of the work for which this permit is issued P.L.
(Sec 3097, Civ. C.). SIDE . 1
0 0 0 0 0
—
P.I.
m Lender's Name •T - 2 - 66 (175
Lender's Address P.C. Fee E (J Permit Fee �fiy.1S
/ / oe
I certify that I have read this application and state that the 660755
G-3e 1. Issuance Fee 6• J CJ
a above information is correct. I agree to cam with,all Count
9 comply Y Investigation Fee 0 61 5-83
ordinances and Slate laws relating to building construction, Total Fae
a and hereby authorize representatives of this County to enter
Upon the ah ve-mentioned aperty f i pection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signals of ApRI¢aM r Agent Dale .®s